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BOOK  6  18. 92. K 
KERLEY  n  TREA 
CHILDREN 


3    TIS? 


TREATMENT 


DISEASES  OF  CHILDREN 


BY 

CHARLES  GILMORE  KERLEY,  M.D. 

PROFESSOR  OF    DISEASES  OF    CHILDREN,   NEW    YORK    POLYCLINIC    MEDICAL    SCHOOL 

AND  hospital;     ATTENDING   PHYSICIAN   TO   THE   NEW    YORK   INFANT  ASYLUM; 

ATTENDING  PHYSICIAN  FOR  CHILDREN,   SYDENHAM  HOSPITAL,  NEW  YORK  ; 

ASSISTANT   ATTENDING    PHYSICIAN   TO    THE    BABIES'   HOSPITAL,  NEW 

YORK  ;  PRESIDENT  OF  THE  AMERICAN  PEDIATRIC  SOCIETY,  ETC. 


FULLY  ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1907 


Copjoight,  1907,  by  W.  B.  Saunders  Company 


TO 

MY   PRACTITIONER  STUDENTS 

PAST  AND  PRESENT 


NEW  YORK  POLYCLINIC  MEDICAL  SCHOOL  AND  HOSPITAL, 

AT  WHOSE  SUGGESTION 

THIS  WORK  HAS  BEEN  PREPARED 


PREFACE 


This  work  has  been  prepared  for  the  general  practitioner  of 
medicine.  It  has  not  been  written  with  a  view  to  supplying  the 
needs  of  either  the  specialist  in  children's  diseases  or  the  under- 
graduate student.  The  possibilities  of  therapeutic  measures  in  the 
treatment  of  children  have  greatly  increased  during  the  past  decade ; 
and  the  author's  effort  in  this  volume  has  been  to  present  to  the 
physician  in  active  general  practice,  modern  methods  of  management 
in  greater  detail  than  has  been  attempted  by  the  valuable  books 
already  on  the  market.  The  means  and  methods  suggested  herein 
are  not  drawn  from  the  Hterature,  but  from  experience  based  upon  a 
somewhat  extensive  appHcation  of  the.  principles  evolved  by  the 
author  in  private  and  hospital  practice.  This  book  is  offered,  there- 
fore, with  the  hope  that  it  may  be  of  service  to  other  physicians  in 
caring  for  an  important  group  of  their  patients. 

The  author  wishes  to  acknowledge  his  indebtedness  to  Dr.  James 
F.  McKernon  for  suggestions  in  the  chapters  on  the  diseases  of  the 
ear;  to  Dr.  Thomas  L.  Bennett  for  suggestions  in  the  chapter  on 
Anesthetics;  to  Dr.  N.  Curtice  Holt  for  the  revision  of  the  proof 
sheets,  and  to  Dr.  Royal  Storrs  Haynes  for  the  arrangement  of  the 
index  and  his  valuable  assistance  in  the  preparation  of  the  chapter  on 
Drugs  and  Drug  Dosage. 

Charles  Gilmore  Kerley 

New  York, 


CONTENTS 


General  Considerations 17 

Therapeutics  in  Children  17— Clothing  and  Additional  Requirements 
for  the   Expected  Baby,    19 — The    Young    Mother,   21 — The    Nursery 

laid,    22 — The   Nursing-bottle    and    Nipple,    23 — The   Nursery,    24 

Baskets  for  Early  Exercises,  25 — Care  of  Stump  of  Umbihcal  Cord,  26 — 
Crying,  26— Sleep,  27— Kissing,  28— Baths,  29— Weight,  31— Height,  34 
— Teeth,  35 — Days  to  go  Out  of  Doors;  Indoor  Airing,  36 — Exercise 
Pen,  37 — First  Examination  of  Patient,  39 — Written  Directions,  39 — 
Treatment  of  Individual,  41 — Necessity  of  Method  in  the  Management 
of  Children,  42— The  Sick-room,  43. 

The  New-born 45 

Premature  and  Congenitally  Weak  Infants,  45 — Asphyxia,  48 — Sepsis, 
49 — Cephalhematoma,  50 — Icterus  Neonatorum,  50 — UmbiHcal  Polypi 
51 — Atelectasis,  51 — Mastitis,  52 — Umbilical  Granuloma,  53 —  Hemor- 

I  rhagic  Diseases,  53 — Tetanus  Neonatorum,  54. 

'Nutrition  and  Growth 55 

General  Properties  of  Foods,  59 — Maternal  Nursing,  62 — Wet-nurse, 
73 — Human  Milk,  75 — Cracked  and  Fissured  Nipples,  77 — Caking  of 
the  Breasts,  78 — Depressed  Nipples,  79 — Acute  and  Suppurative  Mas- 
titis in  the  Mother,  79 — Substitute  Breast-feeding,  80 — Artificial 
Feeding,  80— Cow's  Milk,  98— Cream,  107— Difficult  Feeding  Cases, 
108 — Sterilization  and  Pasteurization  of  Milk,  111 — Condensed  Milk, 
114— Peptonized  Milk,  115— Milk  for  Travehng,  116— The  Proprietary 
Foods,  117— Cereal  Gruels,  1 19— Starch-feeding,  119— Food  For- 
mulas, 123 — Habitual  Loss  of  Appetite,  125 — Common  Errors  in  Feed- 
ing, 127 — Diet  from  the  First  to  the  Sixth  Year,  128 — Diet  after  the 
Sixth  Year,  132— How  the  Child  Should  be  Fed,  132— Diet  during 
Illness,  133 — Gavage,  134 — Substitutes  for  Stomach-feeding,  138 — 
The  Delicate  Child,  142 — Marasmus;  Athrepsia;  Infantile  Atrophy, 
150 — Malnutrition  in  Infants,  156 — Tardy  Malnutrition,  158. 

Gastro-enteric  Diseases 160 

Acute  Intestinal  Indigestion,  160 — Persistent  Intestinal  Indigestion, 
161 — Persistent  Intestinal  Indigestion  in  Older  Children,  162 — Colic, 
164 — Bowel  Function,  166 — Vomiting,  176 — Acute  Gastritis  and  Acute 
Gastric  Indigestion,  177 — Chronic  Gastric  Indigestion;  Chronic  Gas- 
tritis, 179 — Lavage;  Stomach-washing,  180 — Dilatation  of  the  vStom- 
ach,  183 — Ulceration  of  the  Stomach,  184 — Congenital  Pyloric  Steno- 
sis, 185 — Prevention  of  Acute  Intestinal  Diseases  of  Summer,  186 — 
Acute  Gastro-enteric  Infection ;  Cholera  Infantum ;  Gastro-enteric 
Intoxication,  191 — Acute  Enteric  Infection,  197 — Acute  Ileocolitis, 
199— Chronic  IleocoUtis,  204 — Mucous  Colitis,  206 — Colon  Irrigation, 
207 — Intestinal  Obstruction,  209 — Appendicitis,  210 — Intussuscep- 
tion, 211 — Inflammation  of  the  Anus,  213 — Fissure  of  the  Anus,  213 — 
The  Intestinal  Parasites,  214 — Prolapse  of  the  Anus  and  Rectum,  216 — 
Ischiorectal  Abscess,  218 — Hemorrhoids,  218 — Rectal  Polypus,  219 — 
Incontinence  of  Feces,  219. 

The  Mouth,  Thro.a.t,  and  Nose 220 

Stomatitis,  220 — Sprue,  223 — Thrush;  Mycotic  Stomatitis,  223 — Can- 
crufn  Oris;  Noma,  224 — Bednar's  Aphthae,  225 — Fissures  of  the  Lips, 
226 — Ulcerations  and  Fissures  at  the  Angle  of  the  Mouth,  226 — Ulcer 
of  the  Frenum  of  the  Tongue,  226 — Geographic  Tongue,  227 — Tongue- 
tie,  227. 


14  CONTENTS 

PAGE 

Diseases  of  the  Respiratory  Tract 228 

Taking  Cold,  228— Acute  Rhinitis  (Coryza;  Snuffles;  Cold  in  the  Head), 
229 — Recurrent  Coryza  and  Angina,  233 — Nasal  Hemorrhage,  234 — 
Throat  Examination,  234 — Faucitis,  235 — Pharyngitis,  236 — Tonsillitis, 
236 — Hypertrophied  Tonsils,  239 — Peritonsillar  Abscess;  Quinsy,  240 
— Retropharyngeal  Abscess;  Suppurative  Retropharyngeal  Adenitis, 
242 — Retropharyngeal  Abscess  (Tuberculous) ;  Caries  of  the  Cervical 
Vertebrae,  245 — Irrigation  of  the  Throat,  245 — Acute  Catarrhal  Laryn- 
gitis, Spasmodic  Croup,  246 — Laryngismus  Stridulus,  251 — Traumatic 
Laryngitis,  253 — Laryngeal  Obstruction,  254 — Foreign  Bodies  in  the 
Larynx,  254 — Persistent  Cough,  255 — Bronchitis,  257 — Recurrent 
Bronchitis,  261 — Bronchial  Asthma,  263 — Bronchopneumonia;  Catar- 
rhal Pneumonia,  266 — Lobar  Pneumonia,  272 — Primary  Pleurisy,  278 
— Secondary  Pleurisy,  279 — Primary  Tuberculous  Pleurisy,  280 — Empy- 
ema, 280 — Double  Empyema,  284 — Empyema  Necessitatis,  284 — Pul- 
monary Tuberculosis   285 — Bronchiectasis,  287. 

Diseases  of  the  Heart 289 

Pericarditis,  289 — Acute  Endocarditis,  290 — Mahgnant  Endocarditis, 
293— Myocarditis,  293— Chronic  Valvular  Disease  of  the  Heart,  296— 
Congenital  Heart  Disease,  299 — Abuse  of  Heart  Stimulants,  299. 

Contagious  Diseases 300 

Care  to  be  Exercised  by  the  Physician  in  Visiting  Contagious  Diseases, 
300  — Quarantine,  300— Diphtheria,  302  —  Intubation,  310  — Scarlet 
Fever,  314 — Whooping-cough;  Pertussis,  321 — Measles,  330 — Chicken- 
pox;  Varicella,  332 — German  Measles;  Rubella,  333 — Mumps;  Epi- 
demic Parotitis,  334. 

The  Urine 335 

Difficult  and  Painful  Urination,  336 — Retention  and  Suppression  of 
Urine,  336 — Incontinence  of  Urine;  Bed-wetting;  Eneuresis,  338 — 
Albuminuria,  342 — Acute  Nephritis,  343 — Chronic  Diffuse  Nephritis, 
348 — Glycosuria,  349 — Diabetes  Insipidus;  Polyuria,  350 — Diabetes 
Mellitus,  350 — Vesical  Calculus;  Stone  in  the  Bladder,  351 — Cystitis, 
351— Acute  Pyelitis,  352. 

The  Male  Genitals 352 

Phimosis,  353 — Paraphimosis,  353 — Balanitis,  354 — Circum.cision,  354 — 
Gonorrhea  in  the  Male,  355 — Orchitis,  355 — Hydrocele,  356 — Unde- 
scended Testicle,  356. 

The  Fem.\le  Genitals 357 

Simple  \'ulvovaginitis,  357 — Gonorrheal  Vulvovaginitis,  357. 

Nervous  Disorders 359 

Headache,  359 — Hysteria,  359 — Infantile  Convulsions,  363 — Night- 
terrors,  365 — Gyrospasm;  Spasmus  Nutans,  365 — Tetany,  366 — 
Chorea;  St.  Vitus'  Dance,  367 — Habit  Spasm,  370 — Epilepsy,  371 — 
Meningitis,  373 — Lumbar  Puncture,  376 — Chronic  Internal  Hydroceph- 
alus, 377 — Acute  Anterior  Poliomyelitis;  Infantile  Paralysis,  378 — 
Diphtheritic  Paralysis,  379 — Multiple  Neuritis,  381 — Facial  Paralysis, 
382— Cerebral  Palsies,  383— Idiocy,  384— Erb's  Palsy;  Obstetric  Par- 
alysis, 386 — Hiccough,  387 — Angioneurotic  Edema,  387. 

Syphilis 389 

Primary  Congenital  Syphilis,  389 — Tardy  Hereditary  Syphilis,  391 — 
Tardy  Malnutrition  of  Syphilitic  Origin,  392. 

Deformities 395 

Inguinal  Hernia,  395— Umbilical  Hernia,  396— Ventral  Hernia,  397— 
Spina  Bifida,  397 — Harelip,  398 — Hematoma  of  the  Sternocleidomas- 
toid Muscle,  398— Cleft  Palate,  398. 

Diseases  of  the  Skin 400 

Eczema,  400 — Urticaria;  Hives;  Nettle-rash,  407 — Impetigo  Conta- 
giosa, 408 — Pemphigus,  408— Erythema  Nodosum,  409 — Erythema 
Multiforme,  410 — Rhus  Poisoning;  Ivy  Poison,  410 — Furunculosis ; 
Boils,  411— Scabies;    Itch,  412— Bed-sores;    Decubitus,   413— Pediculi, 


CONTENTS 


15 


PAGE 

413 — Tinea  Tonsurans;  Ring-worm  of  the  Scalp,  414 — Tinea  Circinata, 
416— Miliaria;   Prickly  Heat,  416. 

Diseases  of  the  Ear 418 

Earache,  418 — Acute  Otitis,  418 — Deafness,  422 — Chronic  Suppurative 
Otitis,  422 — Mastoiditis,  423. 

Glandular  Diseases 424 

Acute  Adenitis,  424— Persistent  Adenitis,  425— Adenoids,  426— Retro- 
pharyngeal Adenitis,  429 — Tuberculous  Adenitis,  430. 

Heredity  and  Environment 43I 

Habits,  432— Masturbation,  433. 

Constitutional  Disorders 437 

Icterus;  Obstructive  Jaundice,  437 — Obesity,  438 — The  Anemias  of 
Infancv  and  Childhood,  438 — Rachitis,  441 — Scorbutus;  Scurvy,  445 — 
Sporadic  Cretinism;  Infantile  Myxedema,  445 — Status  Lymphaticus, 
449 — Purpura,  449— Hemophilia,  450. 

Infectious  Fevers 452 

Influenza,  452 — Malaria,  454 — Typhoid  Fever,  456 — Erysipelas,  461 — 
Rheumatism,  463 — Peliosis  Rheumatica,  468 — Acute  General  Peritoni- 
tis, 469 — Tuberculous  Peritonitis,  469 — DactyHtis,  470 — Tuberculous 
Bone  Disease,  471 — Glandular  Fever,  471 — Cyclic  Vomiting,  472. 

Temper.^ture  in  Children 474 

Obscure  Elevations  of  Temperature,  477 — Cold  Sponging  in  Fever,  480 — 
The  Cool  Pack,  481— Bathing  the  Sick,  483. 

Vaccination 484 

Instructions  for  the  Summer 487 

Rules  for  the  Care  of  Dispensary  Infants  and  Young  Children  during 
the  Summer,  489 — Summer  Resorts,  491. 

Therapeutic  Measures 493 

Counter-irritants,  493 — Anesthetics,  494 — Colon  Flushing,  496 — Alco- 
hol, 497 — Heat  as  a  Therapeutic  Agent,  498 — Cold  as  a  Therapeutic 
Agent,  499 — The  Therapeutic  Value  of  Climate,  500 — Promiscuous  Use 
of  Drugs  by  the  Family,  501 — Unpalatable  and  Nauseating  Drugs,  502. 

Gymnastic  Therapeutics 505 

Rules,  505— Posture  and  Breathing,  508— Breathing,  513— Flat  Chest, 
516 — Kyphosis,  518 — Scoliosis,  521 — Congenital  Ataxias,  526 — Ante- 
rior Poliomyelitis,  539 — Constipation,  541 — Flat-foot,  543. 

Drugs  and  Drug  Dosage 545 

For  Internal  Use,  545 — For  External  Use,  558. 

Index 563 


THE  TREATMENT 

OF  THE 

DISEASES  OF  CHILDREN 


GENERAL  CONSIDERATIONS 

THERAPEUTICS  IN  CHILDREN 

If  I  were  asked  what  I  considered  the  chief  requisite  for  the 
successful  practice  of  pediatrics  by  a  competent  physician  I  would 
answer:  The  education  of  the  mother.  It  is  impossible  to  do  even 
fairly  good  work  in  diseases  of  children  without  proper  home  co- 
operation. The  simple  giving  of  a  direction  is  never  followed  out 
as  well  as  when  the  reason  for  it  is  understood. 

Much  of  our  beneficial  results  is  due  to  the  therapeutic  influences 
of  remedies  outside  of  the  realm  of  drugs.  Thus,  diet,  fresh  air, 
cold,  heat,  massage,  electricity,  climate — all  are  important  therapeu- 
tic agents  in  the  diseases  of  children.  Successful  therapy  in  children 
involves  an  understanding,  a  knowledge  of  detail,  greater  perhaps  than 
in  any  other  line  of  medical  work.  It  not  infrequently  is  an  absence  of 
such  knowledge  on  the  part  of  medical  men  which  explains  a  great 
deal  of  the  therapeutic  doubt  existing  at  the  present  time.  Thera- 
peutic nihilism,  as  far  as  pediatrics  is  concerned,  means  ignorance  and 
incompetency.  The  time  when  the  physician  can  make  a  diagnosis, 
and  cease  his  interest  in  the  treatment  of  the  case  is  past.  One  of 
two  things  will  happen  in  the  absence  of  interest  or  ability  on  the 
part  of  the  physician.  The  faith  of  humanity  in  curative  agents  is 
remarkable,  and  when  the  desired  end  is  not  reached  by  the  first 
physician,  some  other  physician  is  called ;  and  when  he  fails,  the  next 
resort  usually  is  the  charlatan  and  the  proprietary  and  patent 
medicines. 

The  prosperitv  of  the  irregular  schools  of  various  cults  and 
sciences  supposedly  healing  in  character  and  the  consumption  by  the 
people  of  millions  of  dollars'  worth  of  useless  proprietary  and  patent 
drugs  are  to  be  attributed  in  a  large  degree  to  an  indift'erent  ap- 
plication of  therapeutic  measures  on  the  part  of  otherwise  well 
qualified  medical   men.      A  few  great  teachers  of    medicine   have 


1 8  GENERAL   CONSIDERATIONS 

done  an  incalculable  amount  of  harm  by  precept  and  example  in 
their  attitude  toward  therapeutics.  Because  they  were  or  are 
unable  successfully  to  treat  disease  they  assume  that  it  cannot  be 
done.  Thus  therapeutic  doubt,  using  the  term  therapeutics  in  the 
broad  sense,  has  been  in  the  past  boasted  of  by  men  considered 
clever.  Text-books  on  pediatrics  are  not  without  fault  in  encourag- 
ing careless  practice,  with  necessarily  an  absence  of  favorable 
results,  especially  when  they  state  that  "treatment  is  along  sup- 
portive lines."  What  constitutes  "supportive  lines"  in  a  given 
case?  How  is  the  practitioner  to  know  the  author's  mind?  Or, 
again,  perhaps  it  is  stated  that  "free  stimulation"  is  necessary. 
Stimulation  how,  when,  why,  and  by  what  means  is  what  must  be 
known,  in  order  to  achieve  satisfactory  results.  "Treatment  ac- 
cording to  the  indications  of  the  case"  does  not  help  a  puzzled 
physician  to  any  great  extent.  "Treatment  along  the  same  lines 
as  in  adults,"  adds  no  illumination  when  a  desperately  sick  child 
is  the  patient,  and  moreover  is  faulty  teaching,  for  the  reason  that 
the  treatment  in  such  instances  should  never  be  the  same  as  in 
adults.  An  infant  or  young  child  can  never  be  treated  the  same 
as  an  adult,  either  by  drugs  or  other  measures,  unless  we  wish 
more  thoroughly  to  convince  ourselves  of  the  uselessness  of  thera- 
peutic measures.  In  order  to  practise  therapeutics  successfully  in 
children  the  methods  of  the  physician  must  be  flexible  and  adaptable. 
Children  vary  greatly  in  their  physical  and  mental  equipment,  much 
more  than  do  adults.  The  practice  of  pediatrics  is  necessarily 
difficult,  for  every  case  has  to  be  studied  from  its  own  standpoint. 
The  physician  who  invariably  treats  all  his  cases  alike  will  never  do 
the  highest  class  of  work  with  children.  The  man,  for  example, 
who  feeds  all  his  difficult  feeding  cases  after  one  rule  or  pattern  will 
be  sure  to  have  some  other  practitioner  get  his  failures,  which  will 
not  be  few.  A  source  of  disappointment  to  physicians,  particularly 
in  the  treatment  of  young  infants  and  children,  is  in  the  disorders 
of  nutrition.  A  tremendous  amount  of  patience  is  required  in 
dealing  with  such  cases,  and  the  absence  of  prompt  results  is  one  of 
the  difficult  features  he  has  to  contend  with  in  his  relations  with  the 
family.  There  is,  further,  a  distinction  to  be  made  as  to  what  con- 
stitutes good  results.  If  the  infant  develops  into  a  strong  child, 
we  may  chronicle  our  results  as  satisfactory  even  though  a  year  was 
required  before  the  condition  of  the  patient  was  satisfactory.  To 
cause  a  malnutrition  baby  weighing  only  eight  pounds  at  six  months, 
with  marked  milk  incapacity,  to  show  rapid  growth  by  any  method 
of  artificial  feeding  is  unusual,  and  our  results  are  good  if  he  gains  but 
little  during  the  first  few  weeks. 

Chronic  colitis,  tardy  malnutrition,  or  nephritis  may  require 
months  and  years  for  correcting  and  yet  furnish  satisfactory  results. 
In  therapeutics  in  infants  and  children,  particularly  as  regards  the 


CLOTHING,    ETC.,    FOR    THE    EXPECTED    BABY  19 

use  of  drugs,  two  points  are  to  be  kept  in  mind — the  benefit  hoped 
for  and  the  possible  harm  that  may  result.  A  great  deal  of  judgment 
must  be  used  in  the  selection  of  remedies  and  the  means  of  using 
them  lest  our  best  intentions  result  disadvantageously  to  the  patient. 
Thus,  in  bronchitis  and  in  bronchopneumonia  the  ammonium  salts 
are  often  given  in  combination  with  heavy  syrups  such  as  tolu  and 
wild  cherry,  both  possessing  little  or  no  expectorant  value,  but  they 
possess  the  property  of  interfering  seriously  with  the  patient's  diges- 
tion. Doubtless  alcohol  used  indiscriminately  is,  on  the  whole, 
productive  of  more  harm  than  benefit,  largely  through  disturbing  the 
digestion.  Digitalis,  the  salicylates,  and  the  potassium  and  sodium 
salts  are  all  to  be  used  with  judgment  as  to  method  and  time  of 
administration  or  they  will  do  more  harm  than  good.  A  point 
never  to  be  lost  sight  of  in  the  treatment  of  diseases  of  children 
is  the  desirability  of  keeping  the  gastro-enteric  tract  in  the  best 
possible  condition.  In  children  there  are  other  factors  also  that 
bear  upon  the  case  that  tend  toward  good  or  evil.  The  most  careful 
diet  and  the  best  selected  medication  are  of  little  value  if  the  patient 
is  overclad,  kept  in  a  superheated  room  with  anxious,  oftentimes 
nervously  exhausted  persons  in  constant  attendance,  with  the  dis- 
turbance to  the  patient  which  such  attendance  entails.  However, 
it  must  be  remembered  that  absence  of  proper  detail  and  good 
judgment  with  resulting  failures  is  no  argument  against  the  value 
of  therapeutic  measures,  although  it  often  furnishes  the  evidence 
upon  which  the  argument  is  based.  Much  may  be  accomplished,  by 
means  of  prophylaxis,  in  lowering  the  mortality  in  children  under 
five  years  of  age.  In  these  the  educated  mother's  aid  is  invaluable. 
She  will  lay  aside  prejudices  and  unfavorable  family  influences  when 
a  physician's  direction  appeals  to  her  reason.  Marasmus,  malnu- 
trition, and  the  intestinal  diseases  of  summer,  which  directly  or 
indirectly  are  the  cause  of  thousands  of  deaths  yearly,  are  to  a 
large  degree  preventable  if  the  right  step  is  taken  at  the  right  time, 
through  the  earlv  appreciation  of  danger-signals  on  the  part  of  both 
the  physician  and  the  mother. 


CLOTHING    AND    ADDITIONAL   REQUIREMENTS 
FOR  THE  EXPECTED  BABY 

The  physician  should  instruct  the  young  woman  w^ho  for  the 
first  time  expects  to  become  a  mother  as  to  the  necessary  clothing 
and  toilet  articles  which  she  will  need  for  her  convenience  in  the 
care  of  the  child.  A  basket  in  w^hich  all  the  toilet  necessities  for 
the  baby  may  be  kept  together  will  be  found  a  great  convenience 
when  the  time  for  their  use  arrives. 

The  basket  should  be  provided  with  a  good-sized  pin-cushion 
and  pins; 


20  GENERAL   CONSIDERATIONS 

Puff-box  and  puff; 

Soap-box,  containing  castile  soap; 

Infant's  hair-brush  and  fine  comb; 

Eight  ounces  of  a  saturated  solution  of  boric  acid  for  mouth 
and  eyes; 

One-half  pound  of  absorbent  cotton; 

A  package  of  wooden  toothpicks; 

A  flexible  tube  of  white  vaselin ; 

A  bath  thermometer; 

One  yard  of  plain  sterile  gauze; 

Plenty  of  soft  old  linen ; 

Six  of  the  best  baby  towels; 

A  white  eiderdown  blanket  one  and  one-half  yards  long ; 

One  pair  of  small  scissors ; 

A  package  of  nickel-plated  safety-pins  (three  sizes) ; 
Clothing  to  be  provided: 

Forty-eight  cotton  diapers,  made  from  birdseye  cotton  diaper; 
two  sizes  are  necessary: 

(a)  Three  pieces  20  inches  wide. 

(b)  Three  pieces  22  inches  wide. 

One  yard  of  white  flannel  for  belly-bands.  Leave  the  piece  as 
it  is,  to  be  used  by  the  nurse  as  required.  After  the  sixth  week, 
knitted  bands  with  shoulder-straps  are  preferable. 

Four  second-size  silk-and-wool  shirts ; 

Six  pinning  blankets  made  of  white  flannel  with  cotton  bands ; 

Three  flannel  shirts; 

Three  eiderdown  wrappers; 

Three  Cashmere  sacques ; 

Three  bath  aprons  of  shaker  flannel  for  the  mother  or  nurse,  to 
be  used  to  cover  the  baby  after  he  is  taken  from  the  bath ; 

Three  pads,  each  one  yard  square,  and  three  each  one-half  ^-ard 
square.     These  are  necessary  for  the  crib  and  lap. 

Diapers. — Diapers  are  best  made  from  soft  light-weight  goods 
which  absorb  readily.  Birdseye  cotton  diapers  are  satisfactory. 
The  diaper  should  be  removed  when  soiled  and  placed  in  a  covered 
pail  containing  a  carbonate  of  sodium  solution,  one  ounce  to  two 
gallons  of  water.  Before  using,  whether  soiled  with  urine  or  feces 
they  should  be  boiled  and  washed  with  plain  castile  soap.  Several 
rinsings  will  be  required  before  the  napkins  are  dried,  so  as  to  remove 
the  soda  and  the  soap.  They  should  not  be  dried  in  the  nursery. 
The  rubber  protector  used  as  a  cover  for  the  napkin  should  be  used 
only  during  cold  weather  and  when  the  child  is  out  of  doors.  After 
changing  the  diaper  the  mother  or  nurse  must  immediately  scrub 
her  hands  and  nails  thoroughly  with  hot  water,  soap  and  brush. 
A  diaper  washer  unique  in  design  and  satisfactory  in  its  work  is 
the    washer    known   in   the   market    as   Cunnee's    sanitary  napkin 


THE    YOUNG   MOTHER  21 

washer/  This  is  so  constructed  that  it  may  be  attached  to  the  hot- 
water  pipe  of  any  bath-room.  It  does  away  with  the  disagreeable 
features  of  diaper  washing  by  hand  and  lessens  the  dangers  of  con- 
tamination of  food  apparatus  and  food  at  the  hands  of  the  nurse. 

THE  YOUNG  MOTHER 

In  order  to  achieve  success  in  pediatrics,  the  physician  requires 
the  active  cooperation  of  trained  helpers.  The  more  capable  the 
mother  and  nurse,  the  greater  the  success  that  will  crown  his  labors 
when  children  are  his  patients.  The  physician,  therefore,  should 
undertake  the  instruction  of  the  young  mother  in  the  rudiments  of 
the  child's  care.  In  my  own  experience,  the  intelligent  mother, 
regardless  of  her  station  of  life,  has  proved  a  most  satisfactory 
pupil.  Endowed  with  good  common  sense,  with  her  powers  for 
reasoning  well  developed,  and  possessing  an  ability  to  appreciate 
scientific  principles,  her  usefulness  as  a  mother  is  thus  increased 
tenfold. 

In  order  to  secure  her  full  cooperation  and  confidence  she  must  be 
told  not  only  what  to  do,  but  how  and  why  it  should  be  done.  In 
the  matter  of  infant-feeding,  for  example,  if  it  is  explained  to  a 
mother  of  fair  intelligence  that  condensed  milk  and  the  proprietary 
foods,  when  prepared  for  use,  are  weak  in  fat,  weak  in  proteid,  and 
contain  much  less  of  these  nutritive  elements  than  does  mother's 
milk — the  food  which  the  child  has  a  right  to  demand — she  will  at 
once  be  convinced  that  such  food  is  not  suitable  for  her  baby.  It 
will  then  be  comparatively  easy  to  convince  her  that  cow's  milk 
for  the  great  majority  of  infants  is  the  only  suitable  substitute  for 
mother's  milk. 

It  is  my  object  to  have  the  mother  know  as  much  of  child  life 
as  she  is  capable  of  understanding.  She  is  encouraged  to  attend 
lectures  to  mothers  and  mothers'  meetings.  She  is  advised  to 
subscribe  for  mothers'  journals  and  to  buy  books  and  reading-matter 
for  mothers,  for  the  reason,  which  is  perhaps  not  entirely  unselfish, 
that  I  have  had  signal  success  with  the  infants  of  well-informed 
mothers.  The  children  of  such  mothers,  as  the  result  of  a  properly 
regulated  life,  have  better  appetites  and  less  illness;  they  are  stronger 
and  more  vigorous  than  those  indifferently  cared  for.  If  disease 
attacks  them,  they  make  more  prompt  and  satisfactory  recoveries; 
if  an  operation  is  required,  intelligent  mothers  appreciate  its  necessity. 
As  children,  their  offspring  are  better  specimens  of  the  race,  and  as 
adults,  they  will  always  have  reason  to  be  thankful  that  their  mothers 
were  educated  and  efficient  in  child  management. 

A  mother  should  know  what  to  do  in  case  of  sudden  illness  and 
she  should  know  when  to  send  for  the  doctor.     I  teach  the  mothers 

'  Manufactured  by  The  International  Sanitary  Manufacturing  Co.,  Portches- 
ter.  New  York. 


2  2  GENERAL    CONSIDERATIONS 

of  my  patients  never  to  look  lightly  upon  a  sore  throat  or  trust  to 
their  own  judgment  in  dealing  with  it,  with  the  result  that  repeatedly 
cases  of  diphtheria  have  been  on  the  way  to  recovery  when  an 
ignorant  mother  would  be  treating  them  by  home  methods  with  the 
children  growing  rapidly  worse.  By  the  ignorant,  I  do  not  neces- 
sarily mean  the  poor.  Many  of  my  dispensary  mothers  show  sur- 
prising intelligence  and  good  judgment  when  it  is  most  needed. 

A  mother  should  be  taught  never  to  rely  upon  her  own  judgment 
if  a  child  complains  of  persistent  pain  in  the  stomach.  She  is  told 
that  it  oftentimes  means  a  great  deal  more  than  simple  colic.  I 
have  known  precious  lives  to  be  lost  because  the  mother  made  a 
diagnosis  of  colic  and  treated  the  child  for  such  a  condition,  when 
it  had  appendicitis.  A  mother  should  be  instructed  to  stop  milk, 
to  give  a  dose  of  castor  oil  and  a  carbohydrate  diet  with  the  first 
indication  of  summer  diarrhea,  and  then  to  send  for  the  physician,  no 
matter  how  trivial  the  indisposition.  She  is  told  that,  in  the  intes- 
tinal diseases  of  summer,  the  child  is  poisoned  by  a  process  of  bacterial 
infection  in  the  intestinal  contents  and  that  milk  furnishes  the  best 
food  for  the  bacteria  that  cause  the  trouble.  She  is  told  that  the 
child  who  is  badly  fed  and  who  has  repeated  attacks  of  indigestion 
and  diarrhea  during  the  winter  and  spring  will  be  much  more  suscep- 
tible during  the  summer  to  serious  intestinal  involvement ;  and 
that  proper  feeding  and  the  immediate  correction  of  digestive  errors 
are  of  paramount  importance  at  all  seasons  of  the  year.  She  is  told 
how  to  dress  her  child  in  summer.  She  is  taught  the  necessity  of 
fresh  air  at  night  and  the  value  of  outdoor  life  at  all  seasons  of  the 
year;  that  a  so-called  "cold"  is  usually  an  infection  of  the  respiratory 
mucous  membrane  due  to  dusty  ill-ventilated  rooms  or  dusty  streets 
and  not  to  the  fact  that  a  window  was  left  open  for  a  few  moments ; 
that  a  child  cries  from  other  causes  than  hunger ;  that  fever,  whatever 
its  cause,  requires  that  the  child's  food  be  weakened  at  least  one-half 
in  the  bottle-fed,  and  that  an  ounce  or  two  of  water  be  given  before 
nursing  in  the  breast-fed;  that  drug-giving  to  children  is  a  habit 
which  is  to  be  condemned,  the  child  in  health  requiring  little  or 
nothing  in  that  line. 

With  an  educated  mother  not  only  are  our  "results  much  more 
satisfactory,  but  the  annoying  outside  influence  of  officious  relatives 
and  neighbors  is  thus  effectually  neutralized. 


THE  NURSERY  MAID 
In  certain  stations  and  conditions  of  society,  the  young  child  is 
cared  for  by  its  mother  with  the  assistance  of  the  immediate  members 
of  the  family.  In  thousands  of  homes,  however,  a  helper  is  employed 
to  take  charge  of  the  child  or  assist  in  its  care.  The  selection  of  a 
nursery  maid  is  a  matter  of  much  importance.     Schools  for  training 


THE   NURSING- BOTTLK   AND   NIPPLE 


2.3 


nursery  maids  exist  in  New  York  city,  Boston,  Albany,  Newark 
(New  Jersey),  and  doubtless  in  some  other  cities;  but,  although 
such  trained  help  is  greatly  to  be  desired,  the  supply  is  very  limited. 
Some  of  my  best  children's  attendants  have  iDeen  women  who, 
although  they  have  not  passed  the  meridian  of  life,  still  have  reached 
the  seasoned  age  when  the  attractive  qualities  of  policemen  and 
grocery  boys  have  faded  into  a  dim  recollection !  Any  industrious, 
sensible  young  woman  of  quiet  tastes  who  is  fond  of  children,  can  be 
trained  in  a  few  weeks  into  a  most  useful  helper.  The  association 
of  the  nursery  maid  and  child  is  a  close  one,  and  it  is  the  physician's 
duty  to  know  that  the  applicant  is  physically  fit  for  the  position. 

During  the  past  year  the  writer  has  known  of  three  nursery 
maids  who  developed  pulmonary  tuberculosis  while  in  service. 
Not  only  should  the  applicant's  lungs  be  examined,  but  also  the 
mouth,  nose,  and  throat.  Carious  teeth,  and  diseased  conditions 
of  the  throat  and  nose,  should  receive  careful  attention  before  the 
maid  is  allowed  to  assume  the  position.  It  is  also  important  that 
something  of  the  applicant's  previous  life  should  be  known. 

One  of  the  most  important  things  to  know  about  an  applicant 
in  a  large  city,  and  one  most  difficult  for  the  physician  to  discover, 
is  the  matter  of  leukorrhea  or  vaginal  discharge.^  This,  however, 
can  usually  be  discovered  by  the  tactful  young  mother.  Not  only 
should  the  ideal  nursery  maid  be  physically  fit,  she  must  be  mentally 
fit  as  well.  For  proper  mental  and  physical  development,  children 
must  be  entertained  and  pleasantly  employed.  An  ill-natured, 
impatient  nurse  should  be  forced  to  seek  other  employment.  It 
should  not  be  a  task  for  a  child's  attendant  to  play  wdth  him.  A 
woman  should  not  be  condemned,  however,  because  she  fails  with 
any  given  child.  With  a  child  differently  situated,  with  a  different 
temperament,  the  results  may  be  perfectly  satisfactory.  I  have 
known  not  a  few  such  instances. 


THE  NURSING-BOTTLE  AND  NIPPLE 
There  are  two  requirements  that  a  nursing-bottle  must  fulfil: 
It  must  have  a  capacity  sufficient  for  one  full  feeding  and  it  must  be 
so  constructed  as  to  be  readily  cleansed.  The  oval  bottle  (Fig.  i) 
with  rounded  edges  answers  best.  These  may  be  obtained  in  sizes 
of  from  three  to  nine  ounces.  As  many  bottles  are  needed  as  there 
are  feedings  in  twenty-four  hours.  The  bottle  should  be  boiled 
once  a  day,  scrubbed  with  a  stiff  brush  with  hot  borax  water,  and 
remain  in  the  borax  water  until  needed.  Two  teaspoonfuls  of  borax 
to  a  pint  of  water  is  the  strength  usually  used.  Before  using,  bottles 
should  be  rinsed  in  plain  boiled  water.     The  straight,  black  nipple 

'  A  very  severe  gonorrhea  was  recently  contracted  by  one  of   my  patients 
from  a  nursery  maid. 


24 


GENERAL   CONSIDERATIONS 


(Fig.  i)  is  also  preferred,  for  the  reason  that  it  can  be  turned  inside 
out  and  easily  cleansed.  A  nipple  which  cannot  be  turned  should 
never  be  used.  After  using,  a  nipple  should  be  turned  and  scrubbed 
with  a  stiff  brush  and  borax  water — a  tablespoonful  of  borax  to  a 
pint  of  water.  When  not  in  use,  the  nipple  should  be  kept  in  borax 
water.  Before  placing  it  on  the  bottle,  it  should  be  rinsed  in  boiled 
water.  The  nipple  should  be  boiled  once  a  day.  The  blind  nipples — 
those  without  holes — are  the  best.     Holes  of  the 

A  required  size  may  be  made  with  a  red-hot  cam- 

bric needle. 
THE  NURSERY 
The  nursery  should  be  the  largest  and  best 
ventilated  room  in  the  house.  In  a  city  home  it 
is  well  to  have  it  on  the  third  or  fourth  floor  with 
a  southern  exposure.  In  apartments,  quiet  and 
the  possibility  of  free  ventilation  and  sunlight 
must  be  considered  in  selecting  the  room.  For 
the  sake  of  quiet,  the  nursery  should  not  com- 
municate with  the  sleeping-rooms  of  older  chil- 
dren. 

In  placing  children  in  sleeping-rooms  or  in  a 
nursery  or  in  estimating  the  capacity  of  hospital 
wards  for  children,  it  is  to  be  remembered  that  at 
least  one  thousand  cubic  feet  of  air-space  should 
be  allowed  to  each  child. 

The  floor  of  the  nursery  should  not  be  car- 
peted. A  hard-w^ood  floor  is  best.  If  this  is  not 
possible,  covering  the  floor  with  oil-cloth  or  lino- 
leum is  always  possible.  This  can  be  cleaned  with 
a  damp  cloth  every  day.  A  broom  should  never 
be  used  in  a  nursery.  Paint  or  hard  finish  on  the 
walls  is  preferable  to  paper.  There  should  be  at 
least  two  windows  and  an  open  fireplace.  If  pos- 
sible, the  bath-room  should  be  connected  with  the 
nursery,  to  be  used  not  only  for  bathing  the  child 
but  as  a  "changing  room."  The  child's  napkins 
should  not  be  changed  in  its  living-room  if  it  can 
be  avoided.  It  is  needless  to  say  that  napkins  should  never  be  dried 
in  the  nursery. 

Steam  heat  as  ordinarily  used  today  is  the  least  desirable  means 
of  heating,  on  account  of  its  uncertainty.  In  many  New  York 
apartments  of  the  better  class,  the  fires  are  banked  at  lo  p.  m.  ;  the 
temperature  when  the  child  retires  is  from  70°  to  80°  F.  or  more; 
by  five  or  six  o'clock  in  the  morning  a  fall  to  from  50°  to  60°  F.  has 
taken  place.     Such  a  change  in  the  temperature,  with  the  tendency 


Fig.  1.— Nursing-b 
TLE  AND  Nipple, 


BASKETS  FOR  EARLY  EXERCISE  25 

of  children  to  kick  off  the  bed-clothes,  explains  many  cases  of  ton- 
sillitis and  bronchitis.  The  temperature  of  the  nursery  should  be 
kept  as  even  as  possible.  When  for  any  reason  this  cannot  be  con- 
trolled, it  is  best  to  have  two  means  of  heating,  so  that  when  one  fails 
the  other  may  be  used.  The  open-grate  fire  or  a  small  wood-stove 
is  best.  Gas  ought  never  to  be  employed  as  a  means  of  heating  a 
child's  sleeping-room,  on  account  of  the  rapid  exhaustion  of  the 
oxygen  which  results  from  its  use. 

The  furniture  of  the  nursery  should  be  of  the  plainest.  Hard- 
wood chairs  and  tables  with  enamel  or  brass  cribs  or  bedsteads 
should  be  used.  There  should  be  no  article  of  furniture  or  fur- 
nishings in  a  nursery,  that  cannot  be  washed.  There  should  be  in 
the  bath-room  or  in  some  room  adjoining,  a  pail  containing  some 
disinfectant  solution,  such  as  carbolic  acid,  i :  100,  in  which  the 
napkins  are  placed  as  soon  as  soiled. 

There  should  be  two  shades  at  each  window,  a  light  and  a  dark 
shade,  so  that  it  will  be  possible  to  darken  the  room  during  the 
sleeping  time,  as  well  as  to  exclude  the  early  morning  light,  which 
is  the  usual  cause  of  too  early  waking.  Babies  should  be  taught 
to  sleep  until  at  least  six  o'clock  in  the  morning.  This  is  far  better 
for  the  child  and  also  for  the  mother  if  she  occupies  the  same  room. 
The  unnecessary  habit  of  an  early  waking  at  four  or  five  o'clock  will 
in  most  instances  readily  be  broken  by  keeping  the  room  dark. 

The  nursery  should  have  suitable  means  for  ventilation.  For 
this  purpose,  aside  from  the  fire-place,  I  have  found  the  window- 
board  (page  43)  of  no  little  service.  It  can  be  made  of  any  width. 
Ordinarily,  I  have  it  made  about  four  inches  wide.  It  is  sawed 
so  as  to  fit  tightly  under  the  lower  sash.  This  leaves  an  open  space 
corresponding  to  the  width  of  the  board  between  the  upper  and 
lower  sash,  and  allows  the  entrance  of  a  current  of  air  which  is  directed 
upward.  There  should  be  a  thermometer  in  every  child's  living- 
room  or  nursery.  It  should  register  from  70°  to  72°  F.  by  day  and 
from  66°  to  70°  F.  by  night.  The  nursery  should  be  given  an  hour's 
airing  twice  a  day.  The  child  should  sleep  alone  in  its  crib.  It 
should  not  sleep  with  an  adult  or  an  older  child.  The  old-fashioned 
cradle  in  which  generations  have  been  rocked  may  be  an  interesting 
heirloom,  but  under  no  circumstances  should  it  be  removed  from 
its  place  in  the  garret. 

BASKETS  FOR  EARLY  EXERCISES 

It  is  a  mistake  made  in  many  families  to  have  the  baby  in  the 
arms  a  greater  part  of  his  waking  hours.  This  practice  should  be 
discouraged  by  physicians,  for  when  the  child  is  held,  there  is  always 
a  tendency  to  make  him  sit  upright  on  the  arms  or  knee  without 
proper  support.  During  the  early  months  of  life  the  vertebrae  and 
vertebral  ligaments  are  not  sufficiently  developed  to  support  the 


26  GENERAL   CONSIDERATIONS 

heavy  head  and  trunk.  If  this  thoughtlessness  on  the  part  of 
parents  with  its  attendant  dangers  were  explained,  there  would  be 
fewer  cases  of  displaced  scapulae  and  spinal  curvature  to  be  treated 
later  on.  Many  of  the  cases  of  spinal  curvature  which  we  see  are 
the  direct  outcome  of  such  early  abuse  of  the  spinal  column.  Still, 
it  is  not  desirable  that  the  child  should  constantly  occupy  its  crib. 
A  large  clothes-basket  in  which  a  thick  blanket  and  pillow  have  been 
placed  furnishes  a  safe  playground  for  a  small  baby.  For  the  first 
few  months  he  will  lie  on  his  back  and  amuse  himself  in  his  own 
peculiar  way.  After  the  sixth  month,  when  he  may  be  allowed  to 
sit  up  for  a  short  time  each  day,  a  pillow  should  be  placed  behind 
his  back  for  support.  The  basket  furnishes  plenty  of  room  for  toys 
and  other  means  of  entertainment.  When  the  child  begins  to  stand 
and  attempts  to  walk,  the  basket  period  is  at  an  end  and  the  exercise 
pen  (page  37)  should  be  brought  into  use. 

THE  CARE  OF  THE  STUMP  OF  THE  UMBILICAL  CORD 
The  space  devoted  to  the  care  of  the  umbilical  cord  might  seem 
out  of  place  in  a  work  of  this  nature.  The  excuse  for  it  is  the  fre- 
quent appearance  in  private  practice  and  in  out-patient  clinics  of 
infants  with  umbilical  polypi,  granulomata,  suppurating  umbilical 
stumps,  or  an  eczema  involving  a  considerable  area  about  a  moist, 
actively  secreting  umbilicus.  The  management  of  granuloma, 
polyp,  and  localized  eczema  about  the  umbilicus  has  been  referred 
to  elsewhere.  In  order  to  secure  a  rapid  and  complete  cicatrization 
after  the  cord  falls,  it  is  always  desirable  to  keep  the  parts  dry.  I 
have  used  with  gratifying  success  a  powder  composed  as  follows : 

I^.     Pulveris  acidi  salicylic grs.  x 

Pulveris  acidi  borici grs.  xxv 

Pulveris  amyli 

Pulveris  zinci  oxidi aa  5  ss 

Over  this  powder,  which  is  used  freely  in  the  open  wound,  is 
placed  a  pad  of  gauze  to  hold  it  in  position.  The  dressing  should 
be  changed  and  fresh  powder  applied  every  time  the  child  is  fed. 
For  the  small  unhealthy  granulations  which  will  often  be  present, 
cauterizing  with  a  50  percent  nitrate  of  silver  solution  may  be 
necessary  once  or  twice,  after  which  the  powder  is  used  until  the 
secretion  has  entirely  ceased  and  cicatrization  is  complete. 

CRYING 

It  is  wxll  for  the  young  infant  to  cry  a  little  every  day.  Muscular 
movements  involving  a  greater  part  of  the  body  accompany  the  act 
of  crying  and  furnish  exercise.  Peristalsis  is  increased,  as  is  often 
evidenced  by  a  movement  of  the  bowels  occurring  at  the  time, 
particularly  when  there  is  diarrhea.  In  crying,  deep  breathing  is 
necessary,  the  lungs  are  expanded,  and  the  blood  oxygenated.  The 
well  baby  cries  when  frightened,   or  uncomfortable  from  hunger, 


soiled  napkins,  or  inflamed  buttocks.  He  cries  from  pain,  from 
heat,  from  cold,  from  unsuitable  clothing,  and  during  difficult 
evacuation  of  the  bowels.  He  also  cries  when  displeased  or  angry. 
Authors  are  prone  to  refer  to  the  diagnostic  value  of  an  infant's 
cry.  It  is  my  belief  that  characteristic  cries  are  not  to  be  depended 
upon  sufficiently  to  give  them  a  differential  diagnostic  dignity. 
Children  slightly  but  painfully  ill  may  cry  incessantly  for  an  hour 
or  two.  Thus,  with  intestinal  colic,  where  the  cry  is  loud  and  con- 
tinuous until  the  child  is  relieved  or  until  he  falls  asleep  from  exhaus- 
tion. Earache  is  not  an  infrequent  cause.  The  habitual  criers,  the 
restless  and  vigorous,  crying,  whining  infants,  are  uncomfortable. 
With  ver}^  few  exceptions  the  trouble  will  be  found  in  the  intestinal 
tract.  The  well-trained,  normal  child,  whose  nourishment  is  suitable, 
is  seldom  troublesome.  When  well,  all  babies  are  naturally  good- 
natured  and  happy  in  their  own  way.  Badly  managed,  spoiled 
infants  often  cry  vigorously  when  deft  alone.  When  attention  is 
given  them,  when  they  are  taken  up  and  talked  to,  the  crying  ceases. 
This  readily  tells  us  that  pain  or  discomfort  was  not  an  element  in 
causing  the  cry.  In  these  infants,  discipline,  not  medication,  is 
needed.  The  management  of  the  habitual  crier  involves  the  relief 
of  the  condition  which  causes  the  discomfort,  or  the  most  rigid 
discipline. 

SLEEP 

The  infant  that  sleeps  well  is  almost  always  a  normal,  well-fed 
baby.  Irritability  and  sleeplessness  are  associated  with  indigestion 
more  frequently  than  with  any  other  disorder.  During  the  first 
few  days  of  life,  the  sleep,  in  normal  conditions,  is  almost  unbroken, 
except  when  the  infant  is  fed.  During  the  first  month  the  infant 
sleeps  about  twenty-two  hours  out  of  every  twenty-four.  During 
the  second  and  third  months,  from  tw^enty  to  twenty-two  hours. 
At  the  sixth  month  the  child  should  sleep  from  6  p.  m.  to  6  a.  m. 
without  interruption  other  than  for  feeding  or  nursing,  which  need 
cause  very  little  disturbance.  At  this  age  there  should  be  a  two-hour 
nap  during  the  morning  and  a  two-hour  nap  in  the  afternoon,  although 
it  is  not  well  to  have  the  baby  sleep  after  three  o'clock  in  the  after- 
noon. The  twelve-hour  night  rest  should  be  continued  until  the 
child  is  six  years  of  age.  The  day  naps  will  gradually  be  shortened 
by  the  child.  At  one  year  of  age,  one  hour  in  the  morning  and  two 
hours  in  the  afternoon  suffice.  From  the  eighteenth  month  to  the 
second  year,  the  morning  nap  is  given  up.  Afternoon  rest  for  at 
least  one  and  one-half  hours  should  be  continued  until  the  child 
is  six  years  of  age,  and  longer  if  he  is  inclined  to  be  deHcate.  Regular 
sleep  is  largely  a  matter  of  habit,  and  if  the  infant  is  started  right 
with  suitable  feedings  given  at  definite  times,  followed  bv  the  proper 
period  of  sleep,  but  little  trouble  will  be  experienced  with  sleepless- 


28  GENERAL   CONSIDERATIONS 

ness.  When  sleep  is  disturbed  and  broken,  it  means  bad  habits, 
unsuitable  food,  minor  forms  of  indigestion,  or  positive  illness  of 
some  kind.  Sleep  is  important  for  purposes  of  growth,  not  only  in 
early  infancy  but  throughout  childhood.  Not  a  few  infants  form 
habits  of  sleeping  in  the  daytime  and  being  wakeful  at  night.  This 
is  best  remedied  by  keeping  the  baby  awake,  when  he  should  be,  during 
the  day,  by  entertainment  and  by  keeping  him  in  a  well-lighted 
room.  I  am  sure  that  the  satisfactory  results  which  I  have  had  the 
good  fortune  to  achieve  in  the  treatment  of  secondary  malnutrition 
and  anemia  have  been  due  in  part  to  my  insistence  that  the  child 
sleep  in  a  quiet,  darkened  room  for  two  hours  after  the  noonday  meal. 
The  energy  expended  in  twelve  hours  by  an  active  child  is  incal- 
culable, and  when  a  portion  of  this  energy  is  reserved  and  the  body 
fortified  by  rest  and  sleep  during  the  middle  of  the  day,  it  means  a 
greatly  diminished  daily  expenditure  of  strength  units. 

KISSING 

Such  a  topic  may  be  considered  out  of  place  in  a  work  of  this 
nature,  but  in  taking  up  the  child's  management  in  all  its  details, 
it  is  my  belief  that  a  few  remarks  on  this  subject  are  perfectly  in 
order.  Every  detail  of  the  child's  daily  life  should  be  under  the 
oversight  of  the  ph^^sician,  and  if  he  is  to  do  his  full  duty,  he  must 
give  a  certain  amount  of  voluntary,  unsought  advice.  A  custom 
concerning  which  he  will  not  be  consulted  is  the  matter  of  that 
most  unhygienic  practice  of  kissing. 

A  child  should  never  be  kissed  on  the  mouth,  and  this  is  a  standing 
order  wdth  all  my  patients.  I  have  known,  in  my  own  private 
practice,  of  instances  where  tuberculosis,  diphtheria,  and  syphilis 
have  been  communicated  from  the  diseased  adult  to  the  innocent 
child  by  this  disgusting  practice.  Neither  should  the  child's  hands 
or  fingers  be  kissed,  as  the  hands  and  fingers  of  the  majority  of 
babies  are  in  their  mouths  many  times  an  hour.  If  the  baby  is 
the  first  one  that  has  graced  the  household,  and  must  be  kissed, 
this  can  be  accomplished  with  the  least  damage,  if  the  kiss  is  im- 
planted on  the  head  or  forehead.  The  parents  must  make  the  rule, 
and  they  must  set  the  example  by  adhering  to  it  themselves.  Among 
my  patients,  a  nurse  who  is  known  to  have  kissed  the  child  is  pun- 
ished by  dismissal.  Because  an  adult  is  apparently  well,  is  no  excuse 
for  this  indulgence.  Healthy  adults  frequently  have  in  their  mouths 
the  germs  of  tuberculosis,  of  diphtheria,  and  of  other  diseases,  and 
never  suffer  from  their  presence  because  they  are  strong  adults 
w^ith  vigorous  mucous  membranes  which  do  not  furnish  as  favorable 
a  soil  for  the  growth  and  development  of  pathogenic  bacteria  as  do 
the  more  delicate  mucous  membranes  of  the  young.  It  is  criminal, 
therefore,  to  subject  the  child  to  such  dangers.  Scarlet  fever, 
measles,  and  whooping-cough  are  all  most  readily  transmitted  at 


BATHS 


29 


the  beginning  of  an  attack  through  the  close  contact  required  by 
a  kiss. 

Kissing  should  not  be  allowed  among  children.  Little  girls  are 
very  prone  to  follow  the  customs  of  their  mothers,  whether  good  or  bad ; 
hence,  the  necessity  of  advice  in  this  direction  which  will  be  partic- 
ularly impressed  upon  the  physician  if  he  will  observx'  the  inter- 
change of  bacteria  which  takes  place  on  the  sailing 
or  arrival  of  any  of  our  large  ocean  steamers ! 

BATHS 

The  newly  born  child  should  be  given  daily 
a  basin-bath  with  lukewarm,  boiled  water  and 
castile  soap  until  the  cord  falls  and  the  navel 
heals.  When  this  has  taken  place  the  tub-bath 
may  be  given.  The  temperature  of  the  bath  for 
the  very  young  infant  should  not  be  below  95°  F., 
nor  above  100°  F.  Very  3-oung  children  should 
not  be  kept  in  the  water  more  than  three  min- 
utes. After  the  third  or  fourth  month  a  temper- 
ature of  90°  or  95°  F.  is  best,  the  child  being  kept 
in  the  water  about  five  minutes.  At  this  age  I 
prefer  to  have  the  tub-bath  given  at  night,  just 
before  the  child  is  put  to  bed.  A  basin-bath  may 
be  given  in  the  morning.  When  the  child  is  a 
year  old  and  fairly  vigorous,  the  temperature  of 
the  water  at  the  beginning  of  the  bath  should  be 
90°  F.  This  should  gradually  be  reduced  to  80°  F. 
by  the  addition  of  cold  water,  the  child  being 
vigorously  rubbed  with  the  hand  while  in  the 
water.  The  temperature  of  the  room  should  be 
from  76°  F.  to  80°  F.  during  the  bath,  and  win- 
dows and  doors  should  be  closed,  ^^'hen  removed 
from  the  tub  the  baby  should  be  dried  quickly  and 
thoroughly,  and  the  folds  of  the  skin  should  be 
well  powdered.  A  sponge  should  never  be  used 
in  any  portion  of  the  bathing  process.  It  should 
never  be  included  in  the  nursery  outfit.  It  is 
never  clean  after  it  has  once  been  used.  vSome 
children  have  a  dread  of  the  bath,  and  cry  fran- 
tically when  placed  in  the  water.  This  is  due  to 
fear,  and  may  usuallv  be  overcome  by  placing  a  sheet  over  the  tub 
and  lowering  the  child  on  it  into  the  water. 

The  Cold  Douche. — For  "  runabouts  "  from  two  to  three  years  old 
it  may  not  be  wise  to  use  water  below  70°  F.,  but  many  patients 
over  three  years  have  the  water  applied  in  the  form  of  a  cold  douche 
after  the  cleansing  bath,  during  the  entire  twelve  months  at  the 


m 


i'if% 


Fig.  2.— Bath    Ther- 
mometer. 


30  GENERAL    CONSIDERATIONS 

temperature  at  which  it  runs  from  the  faucet.  In  winter,  in  New 
York  houses,  this  ranges  from  50°  to  60°  F. 

In  giving  the  cool  douche  the  child  should  stand  in  warm  water 
covering  the  ankles.  The  douche  may  be  used  in  the  form  of  a 
spray  or  shower  or  the  water  may  be  applied  by  means  of  a  sponge 
moistened  with  it  at  the  desired  temperature.  The  head,  if  the 
showier  or  spray  is  used,  should  be  suitably  protected  by  an  oil- 
skin or  rubber  bathing  cap. 

After  the  cold  douche  there  should  be  a  vigorous  friction  of  the 
skin  with  a  rough  towel.  If  there  is  not  a  quick  reaction,  if  the  skin 
does  not  become  warm  and  glowing,  warmer  water  should  be  used. 
So  also  with  blueness  of  the  extremities  and  "goose  flesh,"  use 
water  less  cold,  but  do  not  discontinue  the  douche. 

In  the  great  majority  of  homes  the  bathing  of  the  children  can 
be  carried  on  with  greater  convenience  immediately  before  their 
bedtime.  The  child  should  receive  the  warm  bath  and  the  cool 
douche,  and  then,  in  night-clothes,  a  warm  wrapper,  and  suitable 
foot  covering,  he  should  eat  his  supper.  How'ever,  if  this  time  is  not 
convenient,  he  may  be  given  the  evening  meal  at  5.30  or  6.30,  followed 
in  one  hour  bv  the  bath  and  bed. 

Tub-baths  for  Fever. — Place  the  child  in  water  at  a  tempera- 
ture of  95°  F.  and  reduce  to  75°  F.  or  80°  F.  by  the  addition  of  ice 
or  cold  water.  The  duration  of  the  bath  should  not  be  more  than 
ten  minutes,  constant  friction  being  maintained  during  the  entire 
process. 

Basin  Bathing  for  Fever. — Add  eight  ounces  of  alcohol  to  a 
quart  of  water  at  a  temperature  of  70°  F.  The  child  is  stripped  and 
covered  with  a  flannel  blanket,  and  the  entire  body  sponged  with 
this  solution  for  ten  or  fifteen  minutes. 

Either  the  tub-bath  or  the  basin-bath  may  be  used  by  the  mother 
in  case  of  sudden  high  fever — 104°  to  105°  F. — before  the  physician 
arrives.     She  should  be  so  instructed. 

Bathing  for  Comfort  in  Hot  Weather. — The  basin-bath  and 
tub-bath  may  also  be  used  as  a  means  of  relief  during  very  hot 
weather.  One  or  two  basin-baths  a  day,  with  a  tub-bath  at  bedtime 
during  this  trying  season,  will  give  the  child  much  relief,  and  help 
him  to  pass  safely  through  it.  The  very  young  feel  the  extreme 
heat  most  acutely,  and  endure  it  with  difficulty.  I  know  of  nothing 
else  that  will  give  a  restless,  uncomfortable,  heat -tormented  child 
such  a  refreshing  sleep  as  w^ill  a  cool  basin-bath. 

Mustard  Bath. — A  mustard  bath  is  prepared  by  adding  a 
heaping  tablespoonful  of  mustard  to  six  gallons  of  warm  water. 
One  of  the  uses  of  the  mustard  bath  is  in  the  treatment  of  convulsions ; 
it  will  be  found  useful  also  for  nervous  children  who  sleep  badly. 
Two  or  three  minutes  in  the  mustard  water,  followed  by  a  quick 
rubbing  immediately  before  going  to  bed,  is  oftentimes  all  that  will 
be  required  to  induce  refreshing  sleep. 


WEIGHT  3 1 

Brine  Bath. — A  brine  bath — an  even  tablespoonful  of  salt  to 
one  gallon  of  water — is  of  great  service  with  very  delicate,  poorly 
nourished  children.  Its  action  is  that  of  a  tonic.  If  the  child  is 
thoroughly  soaped  and  washed  with  plain  water,  and  then  immersed 
in  the  brine  bath,  no  further  tubbing  is  necessary.  The  child  should 
be  kept  in  the  bath  for  five  or  ten  minutes,  constant  friction  being 
continued  during  the  entire  time. 

Soda  Bath. — The  soda  bath  is  of  some  service  in  cases  of  prickly 
heat  from  which  many  children  suffer  during  the  summer.  A 
tablespoonful  of  bicarbonate  of  soda  should  be  added  to  each  half 
gallon  of  water  used.  The  temperature  of  the  water  should  be  that 
to  which  the  child  is  accustomed.  From  two  to  four  minutes  in  the 
water  suffices.  There  should  be  little  or  no  friction  of  the  skin. 
The  child  should  be  dried  with  soft  towels. 

Bran  Bath.— The  bran  bath  also  is  of  service  in  prickly  heat. 
One  cup  of  bran  is  mixed  with  the  water  in  the  bath-tub  and  the 
same  method  employed  as  for  the  soda  bath. 

Starch  Bath. — The  starch  bath  also  is  useful  in  prickly  heat. 
One-half  cupful  of  powdered  laundry  starch  is  mixed  with  the  water 
in  the  bath-tub,  and  the  same  method  employed  as  for  the  soda  bath. 

Hot  Bath. — Place  the  child  for  from  three  to  five  minutes  in 
water  which  has  been  raised  to  a  temperature  of  105°  or  110°  F. 
Constant  friction  of  the  extremities  is  maintained  while  in  the  water. 

WEIGHT 

The  average  weight  of  the  full-term  newly  born  infant  varies 
from  six  to  nine  pounds.  Some  are  born  at  term  weighing  less  than 
six  pounds  and  a  few  weighing  over  nine  pounds,  but  in  the  great 
majority  the  birth-weight  will  be  found  between  these  figures.  Holt 
found  from  a  study  of  the  records  of  three  large  maternity  institu- 
tions in  New  York  city  as  follows : 

The  average  weight  of  568  females  was  7.16  pounds. 

The  average  weight  of  590  males  was  7.55  pounds. 

Every  family  which  can  afford  it  should  have  a  scale  (page  33) 
for  weighing  the  baby,  for  only  by  regular  weighing  during  infancy 
and  childhood  can  we  gain  an  accurate  knowledge  of  the  growth  of 
the  child.  During  the  first  five  days  of  life  there  is  usually  a  loss  in 
weight  of  from  four  to  six  ounces.  After  this  initial  loss,  which  may 
be  expected  but  which  does  not  always  occur,  a  weekly  gain  in  weight 
is  to  be  looked  for,  the  child  regaining  the  birth-weight  on  the  eighth 
or  tenth  day.  At  first  it  is  advisable  to  weigh  twice  a  week,  or 
even  daily,  if  the  child  is  not  progressing  satisfactorily.  After  the 
second  month,  when  he  is  making  satisfactory  progress,  a  weekh- 
weighing  will  answer,  and  this  should  be  continued  until  the  child 
is  one  year  of  age.  During  the  second  year,  bi-monthly  weighings 
are  sufficient.     Girls  of  the  same  age,  after  the  first  year,  will  average 


32  GENERAL    CONSIDERATIONS 

from  one-half  to  one  pound  lighter  than  boys.  During  the  third 
year,  monthly  weighings  will  be  sufficient  to  enable  one  to  keep 
in  touch  with  the  child's  condition.  During  the  first  six  months 
of  life  a  weekly  gain  of  from  four  to  eight  ounces  has  been  made 
by  the  well  children  under  my  care.  When  a  child  does  not  make 
at  least  an  average  gain  of  four  ounces  weekly,  I  do  not  put  him  in 
the  "doing  well"  class,  but  look  into  his  care  and  nutrition  to  learn 
what  is  wrong.  Children  vary  in  their  growing  capacity.  Some 
will  increase  in  weight  rapidly,  gaining  three  ounces  a  day,  which  I 
have  seen  in  some  cases,  while  others  will  make  a  slower  gain  and  yet 
be  perfectly  well.  Through  the  care  of  many  children,  I  have  come 
to  regard  four  ounces  as  the  minimum  weekly  gain  for  a  well  child. 
In  a  well  infant  the  birth-weight  should  be  doubled  by  the  fifth  or 
the  sixth  month,  and  in  one  year  his  weight  should  be  a  little  over 
two  and  one-half  times  that  at  birth.  During  the  second  year  a  gain 
of  from  five  and  one-half  to  seven  pounds  will  usually  result  under 
proper  conditions.  During  the  third  year  from  five  to  six  pounds 
will  be  added.  At  the  fifth  year  the  weight  should  be  in  the  neighbor- 
hood of  forty-one  pounds.  It  is  not  to  be  inferred  that  these  are 
arbitrary  figures  or  that  perfectly  well  children  may  not  be  under 
or  above  the  figures  given  at  the  ages  mentioned.  They  are,  however, 
to  be  regarded  as  the  averages  for  the  different  ages. 

A  weight  chart  with  its  colored  "normal"  line  will  not  be  found 
in  this  book  and  physicians  are  advised  against  its  use.  Time  and 
again  I  have  seen  well  infants,  though  slow  in  growth,  made  ill  by 
overfeeding,  in  the  vain  attempts  of  an  ambitious  mother  or  nurse 
to  keep  her  infant  up  to  the  "  normal "  line.  It  may  be  said  that  the 
weekly  weighing  might  have  similar  effect;  not  so.  Here  there  is 
nothing  for  comparison — no  normal  red  line  staring  the  mother  in 
the  face. 

The  weighing  alone  is  not  sufficient  to  tell  us  absolutely  as  to 
the  development  of  children.  I  have  seen  condensed-milk  babies  who 
showed  a  most  satisfactory  weight  curv^e,  3^et  who,  on  examination, 
were  bv  no  means  up  to  the  requirements  for  their  age  as  regards 
their  bone  and  muscle  development.  A  nursing  or  bottle  baby 
should  be  examined  once  a  month  in  order  to  determine  if  the  prog- 
ress is  along  the  desired  lines  as  shown  by  the  condition  of  the 
teeth,  the  fontanel,  the  long  bones,  and  the  muscles. 

The  following  table  from  Holt's  "  Diseases  of  Infancy  and  Child- 
hood" gives  the  weight  and  height  of  children  from  birth  to  the 
sixteenth  year.  The  weights  under  five  years  are  in  children  without 
clothing.  After  the  fifth  year  the  weight  of  the  clothing  is  to  be 
deducted.  The  average  weight  of  house-clothing,  according  to 
Holt,  who  quotes  Bowditch,  is  at  the  fifth  year  2.8  pounds  for  both 
sexes;  at  the  seventh  year,  3.5  pounds  for  both  sexes;  at  the  tenth 
year,  5.7  pounds  for  boys  and  4.5  pounds  for  girls;  at  the  thirteenth 


WEIGHT  33 

year,  7.4  pounds  for  boys  and  5.6  pounds  for  girls;  at  the  sixteenth 
year,  9.7  pounds  for  boys  and  8.1  for  girls.  These  weights  must 
be  deducted  from  the  gross  weights  in  order  to  obtain  the  net  weights 
of  the  children.  The  season  of  the  year,  of  course,  would  make  some 
difference  as  to  the  weight  of  the  clothing,  although  this  point  is 
not  mentioned  by  the  observers. 

Age.  Sex.  Weight.  Height. 

Pounds.  Inches. 

Rirth  ^^°y" ^-^^       20.6 

^*"^ \  Girls 7.16  20.5 

,,                             /Boys 16.0  25.4 

6  "^°"^^^^ 1  Girls 15.5  25.0 

,,                             [Boys 20.5  29.0 

12  months |  ^j^ 19  8  28.7 

,,  (Boys 22.8  30.0 

18  months |  ^j/^^ 22.0  29.7 

/Boys 26.5  32.5 

2  years (  ^irls 25.5  32.5 

/Boys 31.2  35.0 

^  y^""'^ \  Girls 30.0  35.0 

/Boys 35.0  38.0 

4  years |Qi4 34  0  38.0 

/Boys 41.2  41.7 

5  years (Qij-ls 39.8  41.4 

/Boys 45.1  44.1 

6  years [q;/^^ 43.8  43.6 

/Boys 49.5  46.2 

7  years |  Qirls 48.0  45.9 

/Boys 54.5  48.2 

8  years {  Qi4 52.9  48.0 

/Boys 60.0  50.1 

9  years [  Qi/is 57.5  49.6 

/Boys 66.6  52.2 

10  years (  gMs 64.1  51.8 

/Boys 72.4  54.0 

11  years (  Qi^ls 70.3  53.8 

,^  /Boys 79.8  55.8 

12  years |  qj^ 81.4  57.1 

/Boys 88.3  58.2 

1^  years |  Girls 91.2  58.7 

/Boys 99.3  61.0 

1"^  years (  Qi^ IOO.3  60.3 

/Boys 110.8  63.0 

15  years (Gi4 108.4  61.4 

/Boys 123.7  65.6 

16  years |  ^irls 113.0  61.7 

Scales. — A  scale  for  weighing  the  baby  is  a  very  necessary 
adjunct  to  the  nursery  furnishings.  There  are  several  varieties  of 
scales  on  the  market  known  as  "baby  scales."  Their  usual  construc- 
tion is  that  of  a  basket  for  holding  the  baby,  the  basket  being  supported 
by  a  steel  rod  which  rests  upon  a  spring.  A  needle  indicates  on  a 
dial  the  weight  of  the  child.  This  variety  of  scale  is  very  unsatis- 
factory: it  gets  out  of  order  easily,  it  is  expensive,  and  with  a  vigorous, 
kicking  child,  the  rapid  oscillation  of  the  needle  makes  an  accurate 
reading  of  the  weight  a  difficult  if  not  an  impossible  matter.  Further, 
the  weight  capacity  of  these  scales  is  but  twenty  pounds.     AA'hen 


34 


GENERAL   CONSIDERATIONS 


the  child's  weight  reaches  this  figure,  it  necessitates  the  purchase 
of  another  scale.  The  scoop  and  platform  scale  used  by  grocers 
(Fig.  3)  answer  the  purpose  far  better  than  any  other.  They  do  not 
easily  get  out  of  order,  they  weigh  correctly  from  one-half  ounce  to  two 
hundred  and  eighty  pounds,  and  being  very  simple  in  construction 
they  can  readily  be  understood.     The  infant  rests  on  his  back  in  the 


Fig.  3.— Scoop  and  Platform  Scale. 

scoop  during  the  weighing  process ;  older  children  stand  on  the  plat- 
form.    These  scales  are  inexpensive,  costing  but  $3.75.^ 


HEIGHT 

The  length  or  height  of  children  at  the  various  ages  is  for  con- 
venience included  in  the  above  table.  From  the  standpoint  of 
health  or  development,  this  is  of  no  great  significance.  The  length 
at  birth  usually  varies  from  19^  to  21  inches.  Children  suffering 
from  tardy  malnutrition,  particularly  if  syphilitic,  may  be  under- 
sized. Not  a  few  of  the  non-specific  malnutrition  and  anemic  children 
are  tall  and  thin.  It  is  often  a  matter  of  no  little  distress  to  parents, 
that  their  children  are  undersized.  Short  mothers  and  fathers 
cannot  expect  very  tall  children.  They  will  probably  be  larger  than 
the  parents  if  they  get  the  right  care,  but  they  cannot  be  expected 
to  grow  as  much  as  some  of  their  playmates  whose  fathers  and 
mothers  are  tall.  The  height  bears  much  less  relation  to  the  con- 
dition of  the  child  than  does  the  weight. 

^The  scoop  and  platform  scale  may  be  obtained  at  the  Metropolitan  Hard- 
ware Co.'s,  Church  and  Vesey  Streets,  New  York. 


THE  TEETH 


35 


THE   TEETH 

Twenty  teeth  comprise  the  first  set.  In  the  well  child  the  first 
tooth  usually  appears  between  the  sixth  and  the  eighth  months; 
the  first  teeth  may,  however,  in  perfectly  normal  cases,  come  earlier 
or  much  later.  I  have  known  well,  vigorous  children  who  did  not 
get  a  tooth  until  the  thirteenth  month.  The  first  teeth  are  usually 
the  two  lower  central  incisors.  The  four  upper  incisors  and  the 
two  lower  lateral  incisors  appear  normally  between  the  eighth  and 
the  tenth  months.  The  first  four  molars  appear  between  the  twelfth 
and  the  fifteenth  months.  The  four  canines  between  the  eighteenth 
and  the  twenty-fourth  months,  the  four  posterior  molars,  which 
complete  the  first  set,  between  the  twenty-fourth  and  the  thirtieth 
months.  This  regularity  in  the  appearance  of  the  teeth  is  by  no 
means  constant,  even  in  well  children.  I  have  in  several  instances 
seen  the  upper  lateral  incisors  appear  first.  In  delayed  dentition 
the  teeth  are  very  apt  to  appear  irregularly. 

Care  of  the  Teeth. — As  soon  as  the  teeth  appear  they  require 
attention.  Until  the  second  year  is  reached  the  mouth  should  be 
washed  out  at  least  twice  a  day  with  a  solution  of  boric  acid— one 
ounce  to  a  pint  of  water.  This  can  best  be  done  by  means  of  absor- 
bent cotton  wound  around  the  tip  of  a  clean  index-finger  and  after- 
ward dipped  into  the  solution,  when  it  should  be  applied  with 
gentle  friction  to  the  gums  and  teeth.  When  a  child  is  two  years 
old,  it  is  well  to  begin  the  use  of  a  soft  tooth-brush  and  a  simple 
tooth-powder  composed  of  the  following  ingredients : 

I^.     Precipitated  chalk 5j 

Bicarbonate  of  soda 5  j 

Oil  of  wintergreen q.  s. 

The  child  should  also  be  instructed  as  to  the  proper  use  of  a 
quill  toothpick.  The  teeth  of  every  child  over  two  years  of  age 
should  be  examined  by  a  dentist  every  six  months.  If  cavities  are 
discovered  in  the  first  teeth  they  should  be  filled  with  a  soft  filling. 

The  milk  teeth  are  lost  between  the  sixth  and  the  eighth  years. 
They  should  not  decay,  but  fall  out  or  be  forced  out  by  the  second  set. 

The  Permanent  Teeth. — The  permanent  set  comprises  thirty- 
two  teeth.  The  second  dentition  begins  about  the  sixth  year,  and 
is  usually  completed  about  the  twentieth  year,  although  it  may  be 
delayed  several  years.  The  permanent  teeth  appear  in  somewhat 
the  following  order : 

First  molars sixth  year. 

Central  incisors sixth  to  seventh  year. 

Lateral  incisors seventh  to  eighth  year. 

First  bicuspids ninth  to  tenth  year. 

Second  bicuspids ninth  to  tenth  year. 

Canines eleventh  to  twelfth  year. 

Second  molars thirteenth  to  fifteenth  year. 

Third  molars after  the  eighteenth  year. 


36  GENERAL   CONSIDERATIONS 

Dentition. — It  is  claimed  that  the  eruption  of  the  teeth  is  a 
physiologic  process  and  as  such  is  not  productive  of  harm.  In 
normal  well  babies  this  is  generally  the  case.  There  may  be  a 
slight  fever  and  restlessness  with  loss  of  appetite,  associated  with  the 
eruption  of  a  tooth,  but  the  disorder  is  usually  very  temporary  in 
character.  With  delicate  children,  particularly  in  those  who  teethe 
late,  as  in  the  rachitic  when  several  teeth  are  cut  at  one  time,  not 
a  little  inconvenience  may  be  caused  by  dentition.  Even  these 
patients,  however,  rarely  have  grave  digestive  disorders.  In  a  large 
experience  with  teething  infants,  I  have  known  but  one  in  whom 
convulsions  were  apparently  directly  dependent  upon  dentition. 
The  patient  was  a  rachitic  institution  child  who  cut  his  first  tooth  at 
the  ninth  month,  and  with  each  of  the  three  succeeding  teeth,  which 
were  cut  during  the  next  three  months,  there  were  convulsions 
without  any  other  signs  of  illness. 

Temporary  digestive  disorders  are  of  ver}^  frequent  occurrence 
in  this  tvpe  of  child,  during  an  active  dentition.  The  child  may 
be  restless  and  irritable  and  perhaps  there  is  fever  of  a  degree  or 
two.  His  digestive  capacity  is  lessened,  but  the  usual  diet  is  never- 
theless continued.  Fermentative  diarrhea  results,  which  may  be, 
and  often  is,  the  starting-point  of  grave  intestinal  disease.  When 
it  is  apparent  that  the  child's  generally  good-natured  daily  habit  of 
life  is  being  unfavorably  influenced  by  dentition,  the  food  should 
temporarily  be  reduced,  particularly  if  the  weather  is  hot.. 

Breast  babies  may  be  given  water  before  each  nursing  so  as  to 
reduce  the  capacity  for  milk.  In  the  bottle-fed  two  or  three  ounces 
of  the  food  mixture  may  be  removed  from  each  bottle,  replacing 
the  amount  with  boiled  water. 

That  cough,  respiratory  and  skin  diseases  are  immediate  results 
of  dentition  is  without  foundation.  During  active  dentition  when 
the  gums  are  distended  and  swollen  from  pressure,  relief  will  often 
be  furnished  promptly  by  rubbing  through  the  prominent  points 
of  the  tooth  with  a  clean  towel  over  the  index-finger.  Lancing 
alone  may  be  performed,  but  unless  the  tooth  is  well  advanced  it 
is  quite  possible  that  the  gums  will  reunite  over  the  tooth,  forming  a 
cicatrix  which  will  make  the  eruption  more  difficult  than  before. 
If  a  week  or  ten  days'  discomfort  can  be  obviated  by  assisting  a 
tooth  through  the  gum,  I  fail  to  see  any  contraindication  to  such  a 
procedure. 

DAYS  TO  GO  OUT  OF  DOORS;  INDOOR  AIRING 

Phvsicians  are  frequently  consulted  as  to  the  age  when,  and  the 
conditions  under  which,  it  is  permissible  to  take  the  baby  out  of 
doors.  To  answer  this,  the  place  in  which  the  child  lives,  the  season 
of  the  year,  and  the  age  and  condition  of  the  patient  must  be  taken 
into  consideration. 


THE   EXERCISE   PEN  ^7 

A  child,  regardless  of  its  age,  should  never  be  taken  out  in  inclem- 
ent weather.  If  under  one  year,  he  should  not  go  out  if  the  tempera- 
ture IS  below  20°  F.  During  the  midday  heat  of  summer  the  baby 
IS  better  off  m  the  largest  and  coolest  room  in  the  house,  or  on  a 
shady  veranda.  On  very  windy  days  the  young  infant  should  not 
go  out,  nor  when  the  snow  is  melting  in  large  quantities,  but,  although 
unable  to  go  out  on  account  of  unfavorable  conditions  of  the  weather 
there  should  be  no  lack  of  fresh  air,  and  in  such  conditions  children 
should  be  given  an  indoor  airing.  For  this  purpose  the  child  is 
dressed  as  for  the  daily  outing.  All  the  windows  of  the  nursery  or 
some  other  large  room  are  opened,  on  one  side  of  the  room  onlv 
The  doors  should  be  closed,  so  that  currents  of  air  are  avoided  The 
child  IS  placed  in  his  carriage,  suitably  covered,  and  wheeled  about 
the  room  for  an  hour  or  two.  This,  if  done  twice  daily,  answers 
almost  as  well  as  the  actual  outing. 

This  method  will  be  found  very  useful  in  "winter  babies"— 
those  born  during  the  late  fall  or  winter  months.  The  indoor  airing 
may  be  given  for  a  week  or  more,  before  he  is  taken  out.  By  this 
means  the  child  is  gradually  accustomed  to  a  change  of  tempera- 
ture from  that  of  the  average  living-room  to  that  out  of  doors  and 
will  not  be  harmed  when  he  is  finallv  taken  out.  After  an  illness 
also,  it  will  afford  an  earlier  means  of  returning  to  the  daily  outing 
This  method  of  giving  a  child  fresh  air  will  be  found  useful  with  very 
delicate  children  also,  who,  by  reason  of  their  condition,  may  be 
unable  to  go  out  during  the  winter  months,  for  several  weeks  at  a 
time.  There  are,  however,  but  few  days  during  the  winter  that  are 
too  cold  or  too  stormy  for  the  indoor  airing. 

THE  EXERCISE  PEN 

In  another  chapter,  in  speaking  of  "colds"  and  how  children  are 
exposed  to  the  influences  which  might  bring  about  what  is  known 
as  a  "cold,"  the  custom  of  allowing  a  child  to  sit  on  the  floor  and 
play,  at  all  seasons  of  the  year,  is  referred  to  as  a  most  frequent  means 
of  exposure.  There  is  always  a  current  of  air  near  the  floor,  as  one 
readily  discovers  by  resting  his  hand  on  the  floor,  on  a  cold  winter 
day;  further,  the  floor  of  the  average  house  is  naturally  the  most 
unclean  part  of  the  dwelling.  Here  dust  gathers  and  dirt  from  the 
street  collects  as  it  is  brought  in  on  the  feet  of  older  members  of  the 
family.  On  this  necessarily  unclean  floor,  the  young  child  is  per- 
mitted to  spend  a  considerable  portion  of  his  waking  hours.  It  can 
readily  be  seen  that  countless  numbers  of  bacteria  may  be  trans- 
ferred through  the  medium  of  the  hands  from  the  floor  to  the  child's 
mouth.  Rugs  and  pillows,  which  are  sometimes  used,  while  cleaner 
than  the  floor,  are  of  little  assistance  in  preventing  drafts. 

Exercise  is  very  necessary  for  the  child's  proper  growth  and 
development.     He  must  have  an  opportunity  and  place  in  which  to 


38 


GENERAL   CONSIDERATIONS 


creep,  walk,  and  run.  In  order  that  he  may  have  these  advantages 
and  not  be  subjected  to  unfavorable  influences,  I  have  found  the 
exercise  pen  (Fig.  4)  of  the  greatest  service.  After  being  bathed, 
dressed,  and  fed,  the  child  is  placed  in  the  pen,  on  a  rug  or  quilt. 
Toys  are  given  him  and  the  door  is  closed.  He  cannot  come  in  con- 
tact with  the  stove,  he  cannot  roll  downstairs,  and  he  is  in  no  danger 
from  the  rough  play  of  older  children.  He  is  given  an  opportunity 
for  active  exercise  without  a  possible  chance  of  injury. 

The  pen  can  be  made  of  any  size,  but  the  usual  size  is  four  feet 
square.  It  can  be  made  of  any  hght-weight  wood,  pine  generally 
being  used.     The  legs  of  the  pen  should  be  at  least  twelve  inches 


Fig.  4.— The  Exercise  Pen. 


long,  bringing  it  well  off  the  floor.  The  pen  is  so  constructed  that 
it  may  readilv  be  taken  apart  and  put  together  again,  iron  tenon 
hooks  and  iron  mortices  being  used  to  hold  the  parts  together.  The 
floor  may  be  made  of  any  thin  material.  One-half  inch  pine  boards 
nailed  together,  or  papier-mache  supported  by  narrow  strips  of 
board,  may  be  used.  The  floor  is  supported  by  strips  of  board  about 
one-half  by  two  inches,  which  are  fastened  to  the  inner  side  of  the 
end-pieces.  The  pen  is  best  placed  in  the  corner  of  the  nursery  or 
the  living-room.  Its  size  may  be  determined  entirely  by  the  size  of 
the  room.  During  warm  weather  in  the  country,  it  may  often  be 
used  out  of  doors. 


WRITTEN    DIRIiCTIONS  •  39 


THE  FIRST  EXAMINATION  OF  A  PATIENT 

Upon  being  called  for  the  first  time  to  see  a  patient,  it  is  my 
custom  in  every  case  to  take  a  history.  On  page  40  is  a  copy  of 
one  page  of  the  history  record  which  I  use. 

When  the  history  is  completed  the  leaves  are  placed  in  a  Moore's 
loose-leaf  binder. 

The  patient's  family  history  is  carefully  taken.  The  habit  of 
obtaining  a  complete  and  accurate  record  as  regards  family  peculiari- 
ties in  relation  to  disease  is  often  of  much  service,  subsequently,  if 
not  at  the  time.  Upon  systematic  questioning  only  will  necessary 
facts  be  brought  out  relating  to  tuberculosis,  rheumatism,  syphilis, 
etc.  The  child's  personal  history  includes  the  birth- weight,  the 
rate  of  growth,  the  nature  of  previous  illnesses,  present  weight,  the 
condition  of  the  skin,  eyes,  nose,  heart,  lungs,  tongue,  bowels,  and 
the  temperature.  All  these  points  are  noted  and  recorded.  It  is 
only  by  such  an  examination,  requiring  much  time  and  patience, 
that  we  are  able  to  become  thoroughly  acquainted  with  the  case  in 
hand. 

The  child  must  be  stripped  for  the  examination  when  the  condi- 
tions found  are  entered  in  the  proper  spaces  in  the  history  chart. 
After  the  family  history  has  been  taken  and  the  general  physical 
examination  completed,  we  are  in  a  position  to  devote  ourselves  to 
the  present  condition  of  the  patient.  After  one  has  practised  for  a 
time,  thoroughly  examining  every  new  case,  he  is  not  only  impressed 
with  its  value  as  bearing  upon  the  management  of  the  condition  in 
question,  but  is  also  impressed  with  the  unexpected  pathologic 
findings  in  other  organs,  particularly  the  heart,  throat,  and  lungs. 
The  habit  of  limiting  the  examination  to  feeling  the  pulse,  which 
the  doctor  usually  does  not  feel  on  account  of  the  struggling  child, 
and  the  examination  of  the  tongue,  which  is  usually  alike  unsuccessful, 
merits  the  severest  condemnation. 

WRITTEN  DIRECTIONS 

If  possible,  directions  for  the  care  of  sick  children  should  be 
given  outside  the  sick-room,  so  that  the  physician  may  have  the  un- 
divided attention  of  the  mother  or  nurse.  These  directions  should 
first  be  given  orally  and  thoroughly  explained,  and  then  written 
out  in  detail.  With  the  child  crying,  and  two  or  three  onlookers 
talking,  the  mother  or  nurse  becomes  confused  and  is  almost  sure 
to  misunderstand  or  forget  important  directions. 

If  there  is  not  a  trained  nurse  in  charge  the  doctor  should  show 
the  mother  or  nursery  maid  how  to  perform  the  various  offices  for 
the  child.  She  can  in  a  few  moments  be  taught  how  to  read  the 
clinical  thermometer,  how  to  give  a  sponge-bath  and  an  enema,  and 
how  to  do  many  other  things  which  the  changed  condition  of  the 


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TRKATMICNT   OF   THE    INDIVIDUAL  4 1 

child  requires.     The  use  of  a  croup  kettle,  which  may  be  needed  for 
croup  or  bronchitis,  should  always  be  explained. 

I  have  found  the  printed  form  as  given  below  very  useful  not 
only  in  making  the  directions  absolutely  plain  and  unmistakable, 
but  also  as  a  great  time-saving  measure.  The  expense  of  printing- 
is  but  a  trifle.  Form  A  represents  the  front  of  the  slip.  A  few  minutes 
is  all  that  is  necessary  to  fill  in  the  blank  spaces.  Form  B  represents 
the  back  of  the  slip;  on  this  the  results  of  the  preceding  twelve  or 
twenty-four  hours  are  entered.  One  chart  may  be  made  to  answer 
for  twelve  or  twenty-four  hours,  and  when  the  case  is  finished  we 
have  a  complete  record,  secured  with  the  expenditure  of  little  time 
and  labor. 

FORM  A. 


.  hrs. 
.hrs. 
.  hrs. 
.hrs. 

.hrs. 
.°F. 


Date              Name 

Age                            Disease 

ORDERS. 

Food. 

Temperature  to  be  taken  every .  .  .  hf s. 

Spray  Gargle  Throat  with 

I^   1                                         every.  .  .hrs. 

every . 

I^  2                                         every .  .  .  hrs. 

Irrigate  Throat  with 

I^  3                                         every.  .  .hrs. 

every . 

Whisky                                  every .  .  .  hrs. 

Irrigate  Ear  with 

Brandy                                  every .  .  .  hrs. 

at  .  .°F.,  every. 

Steam  Inhalations               every .  .  .  hrs. 

Irrigate  Colon  with 

using 

at  .  .°F.,  every. 

Sponge  Bath  for.  .  .min.    every.  .  .hrs. 

Counter-irritation  with 

at.  .  .°F.,  if  Temp,  reaches       .  .  .°F. 

Mustard ....  parts 

Cool  Pack  to  be  given  if  Temp,  reaches 

Flour       ....  parts 

.  .  .°F.,  and   continued  until  Temp. 

to                                           every . 

falls  to.  .  .°F.,  using  water  at.  .  .  .°F. 

Give  Enema  of  Soapsuds 

Saline             at 

at .  .  .  o'clock  if  necessary. 

FORM 

B. 

Date 

CLINICAL  NOTES. 

hour. 

Temperature       °F.       °F.       °F.       °F. 

^F.       °F. 

Pulse 

Respiration 

Sleep 

Nourishment 

Skin 

Tongue 

Throat 

Vomiting 

Lungs 

Stools  no.  in  24  hr. 

character 

Heart 

Abdomen 

Urine  amt.  oz.  in  24  hrs. 

Nervous  Symptoms 

Blood 

Special  Symptoms 

TREATMENT   OF   THE   INDIVIDUAL 

In  these  days  of  specialization,  in  associating  with  medical  men 

in  consultation  or  otherwise,  one  is  sometimes  impressed  with  the 

fact  that  there  is  a  tendency  for  the  patient,  the  individual,  to  be 

lost  sight  of,  to  be  overshadowed  by  the  immediate  disease  or  con- 


42  GENERAL   CONSIDERATIONS 

dition  from  which  he  may  be  suffering.  In  children  the  success  of 
the  treatment  in  practically  every  chronic  ailment  depends  upon  the 
vitality  of  the  individual  patient  and  his  powers  of  resistance  as 
a  whole,  to  a  much  greater  degree  than  is  the  case  with  the  adult. 
The  object  of  taking  up  this  subject  is  not  to  be  unkindly  critical, 
but  to  call  attention  to  one  phase  of  the  management  of  children 
which  is  not  sufficiently  appreciated  by  many  who  have  to  deal  with 
them  in  their  professional  work.  It  is  not  at  all  infrequent  to 
see  poorly  conditioned  children  who  have  been  treated  for  months 
by  local  measures  for  a  skin  affection,  recover  without  any  local 
treatment  whatever,  other  than  an  attempt  perhaps  to  relieve  the 
itching,  when  their  lives  are  ordered  according  to  the  requirements 
of  the  growing  child,  as  regards  nutrition,  bowel  evacuation,  sleep, 
suitable  clothing,  fresh  air,  and  rational  exercise.  I  have  seen  cases 
of  chronic  rhinitis  and  bronchitis  which  had  persisted  for  weeks 
respond  promptly  when  local  measures,  sprays  and  douches,  and 
the  internal  use  of  drugs  were  suspended  and  the  child's  life  directed 
along  rational  lines.  Those  who  treat  tuberculous  and  other  chronic 
bone  diseases,  chronic  otitis,  chorea,  and  hysteria,  are  to  be  reminded 
that  their  work  is  not  half  finished  when  thev  have  completed  the 
usual  daily  or  weekly  routine  treatment.  In  these  chronic  ailments 
it  is  folly  to  expect — what  a  cure  really  means — a  constructive 
process  on  a  destructive  diet  and  improper  habits  of  life.  Children 
possess  marked  recuperative  powers,  and  the  rapidity  of  progress 
toward  recovery  is  often  most  gratifying  when  right  conditions  are 
instituted.  It  is  the  height  of  folly  to  give  children  iron  for  anemia 
and  allow  them  every  form  of  indiscretion  in  diet.  It  should  always 
be  remembered  that  the  best  results  are  obtained  in  the  treatment 
of  a  child,  whatever  the  nature  of  his  illness,  when  he  has  a  child's 
normal  existence,  and  it  is  only  under  such  conditions  that  satis- 
factory results  of  treatment  can  be  expected. 

NECESSITY  OF  METHOD  IN  THE  MANAGEMENT  OF  CHILDREN 
Among  the  observations  that  have  been  made  during  my  work 
in  pediatrics  among  all  types  and  classes  of  people  I  have  been 
particularly  impressed  with  the  fact  that  some  children  are  the 
source  of  an  immense  amount  of  trouble,  while  others  of  no  better 
health  or  greater  strength  cause  very  little  anxiety  on  the  part  of 
their  parents.  Children  diff'er  greatly  as  regards  individual  traits 
and  disposition,  but  these  can  be  fashioned  to  a  great  extent  by 
proper  management.  The  more  spirited  the  child,  the  greater  need 
of  method  in  its  care.  I  know  mothers  who  are  worn-out,  nervous 
wrecks  for  no  other  reason  than  a  lack  of  system  in  the  management 
of  the  daily  life  of  their  children.  Thorough-going  conscientious 
mothers  they  may  be,  but  thev  represent  that  large  number  of 
mothers  who  have  never  been  tauglit  that  certain  functions  and 


THE    SICK-ROOM  42 

duties  should  be  performed  only  at  certain  definite  times  every  day. 
This  subject  is  considered  not  from  any  moral  standpoint  but  simply 
because  of  its  bearing  upon  health. 

Beginning  with  the  baby  at  birth,  he  should  be  fed  or  nursed  at 
definite  times  and  at  no  others.  Sleeping  should  never  interfere 
with  the  nursing  hours.  The  child  should  have  its  time  for  undis- 
turbed repose  and  a  midday  nap  should  be  insisted  upon  at  a  certain 
hour  until  the  child  is  six  years  old.  The  definite  time  for  meals,  with 
properly  selected  food,  should  be  continued  throughout  adolescence. 
The  child  should  be  bathed  at  a  certain  hour  and  aired  at  a  certain 
hour.  "Runabouts"  should  have  their  hours  for  play  and  should 
retire  at  a  definite  time  every  evening.  vSuch  a  regime  is  conducive 
to  perfect  health,  consequently  to  better  growth  and  development 
and  to  a  stronger  manhood.  It  is  idle  to  say  that  many  parents, 
particularly  among  the  poor,  cannot  conform  to  such  requirements. 
The  poor  are  just  as  anxious  to  do  the  best  for  their  children  as  are 
the  rich,  and  will  do  it  to  the  best  of  their  ability  if  the  reasons  for 
doing  it  are  explained  to  them.  If  they  cannot  reach  the  ideal, 
they  will  attain  to  a  higher  degree  of  efficiency  by  striving  for  it. 
The  trouble  ordinarily  is  not  with  the  mother,  it  rests  more  with 
the  medical  adviser,  who  is  largely  responsible  for  the  ignorance  of 
the  mother  and  the  resulting  harm  to  her  offspring. 

THE  SICK-ROOM 

If  there  is  a  choice  of  rooms  for  the  patient,  as  there  is  in  many 
households,  its  size  and  means  of  ventilation  are  important  points 
to  be  considered  in  its  selection.  During  cold  weather  a  room  with 
southern  exposure,  to  which  the  sun  has  free  access,  should  be  chosen. 
During  the  hot  months  of  summer,  however,  the  cooler  the  room,  the 
better,  provided  the  size  and  ventilation  are  satisfactory.  The 
furnishings  of  the  room  should  be  of  the  simplest,  only  those  articles 
of  furniture  being  allowed  to  remain  which  are  required  for  the 
patient.  So  many  of  the  ailments  of  childhood  are  of  an  infectious 
nature  that  only  articles  of  furniture  should  be  used  that  can  be 
washed.  Curtains,  hangings,  and  plush  furniture  have  no  place  in 
a  sick-room.  A  plain  wood  floor  is  much  better  than  a  carpeted 
one.  Enameled  beds,  plain  wood  or  enameled  chairs  and  tables 
are  best.  A  painted  wall  is  much  better  than  a  papered  one.  A 
fireplace  is  desirable  not  only  for  heating  purposes  but  also  for 
ventilation.  The  successful  treatment  of  severe  illnesses  in  children 
is  often  determined  by  the  careful  attention  to  every  detail  in  the 
care  of  the  patient.  A  child  ill  in  a  dirty,  badly  ventilated  over- 
furnished,  overheated  room  is  from  the  first  at  a  decided  disadvan- 
tage. 

The  Window-board. — A  convenient  and  simple  means  for  ven- 
tilating   the    living-room,   sleeping-room,   or    sick-room   of    a  child 


44 


GENERAL   CONSIDERATIONS 


is  by  what  is  known  as  the  window-board.  A  plain  inch  board  is 
sawed  the  width  of  the  window-frame  and  placed  under  the  raised 
window  in  the  lateral  frame  groove  resting  upon  the  sill.  This  raises 
the  top  of  the  lower  sash  above  the  bottom  of  the  upper  one,  leaving 
a  space  between,  through  which  the  air  enters  with  the  current 
directed  upward.  The  board  may  be  of  any  width — four,  six,  or 
eight  inches.  A  width  of  six  inches  is  commonly  used.  There  are 
various  ventilating  devices  in  the  market.  Those  that  are  of  value 
are  expensive,  and  their  effectiveness  over  the  simple  means  above 
suggested  does  not  warrant  the  expenditure. 


THE  NEW-BORN 

PREMATURE  AND  CONGENITALLY  WEAK  INFANTS 
There  are  comparatively  few  infants  born  before  the  completion 
of  the  twenty-eighth  week  of  pregnancy  that  surA'ive  the  first  year. 
Reported  cases  of  survival  of  those  born  before  that  time  are  usually 
unreliable,  as  they  seldom  take  the  child  beyond  the  third  month. 
The  prognosis  is  influenced  by  the  factors  causing  the  premature 
birth.  If  syphilis  is  present,  the  child  may  survive  but  a  day  or  two. 
Children  whose  births  are  forced  because  of  kidney  disease  in  the 
mother  do  not  appear  to  do  as  well  as  others.  I  have  treated  a 
large  number  of  premature  infants  in  children's  institutions  and 
have  had  anything  but  brilliant  results  with  them.  They  not 
infrequently  live  to  be  two,  three,  or  four  months  of  age  or  older, 
but  on  account  of  their  reduced  vitality  they  readily  succumb  to  the 
slightest  ailment,  a  mild  bronchitis  or  fermentative  diarrhea  being 
sufficient  to  terminate  their  existence. 

In  the  management  of  the  premature  and  delicate  newly  born 
there  are  three  points  to  be  considered — the  air  the  child  gets  to 
breathe,  the  nourishment,  and  the  maintenance  of  bodily  heat.  It  is 
also  to  be  remembered  that  we  are  dealing  wdth  an  undeveloped 
body  which  is  not  ready  for  the  environment  in  which  it  is  placed. 
The  premature  baby  should  be  handled  only  when  necessary,  and 
then  in  the  gentlest  manner.  Bathing  is  often  best  omitted  for 
the  first  few  weeks,  oil  being  used  for  cleansing  purposes.  Because 
of  the  undeveloped  parenchyma  of  the  lungs  unusually  good  fresh 
air  is  required.  Because  of  the  undeveloped  heat-centers  the  body- 
heat  of  these  infants  is  quickly  lost  and  must  be  maintained  by 
artificial  means.  The  stomach  is  small  and  the  digestive  processes 
are  undeveloped  and  weak,  so  that  the  nourishment  should  be  of  the 
most  easily  assimilable  character. 

The  maintenance  of  heat  is  of  the  utmost  importance.  For 
this  purpose  incubators  and  their  various  modifications  have  been 
used  from  time  to  time.  My  experience  with  incubators  has  been 
unsatisfactory.  They  may  bv  careful  watching  maintain  an  even 
temperature,  but  all  that  I  have  used  have  been  defective  in  supply- 
ing fresh  air  to  the  child.  My  incubator  babies  invariably  have 
done  badly.  If  the  electrotherm  (Fig.  5)  is  not  at  hand,  the 
padded  crib  with  the  child  wrapped  in  cotton  and  surrounded  by 
hot-water  bottles  is  the  best  means  of  maintaining  the  temperature. 
A  thermometer  should  rest  between  the  cotton  and  the  bed-clothing 
as  a  guide  to  the  nurses  in  the  use  of  the  hot-water  bottles.     Ordi- 

45 


46 


THE   NEW-BORN 


narily  this  should  register  from  85°  and  95°  F.,  depending  upon  the 
temperature  of  the  child,  whose  rectal  temperature  should  at  first 
be  taken  frequently.  If  there  is  a  tendency  for  his  temperature  to 
be  greatly  reduced — below  95°  F. — more  external  heat  will  be  neces- 
sary than  if  the  temperature  w^ere  97°  or  98°  F.  The  best  device 
among  those  which  I  have  had  an  opportunity  to  obser\'e  for  main- 
taining artificial  heat  is  the  electrotherm  advocated  and  described 
by  Holt,  "Diseases  of  Infancy  and  Childhood,"  1906. 

"These  small  heaters  are  attached  to  an  electric  fixture,  like  a 
drop-light.  A  convenient  size  is  from  ten  to  fifteen  inches.  It  is 
placed  between  two  or  three  thicknesses  of  blankets,  upon  which  the 
infant  lies  in  its  basket  or  crib.  The  degree  of  heat  can  be  regulated 
according  to  the  amount  of  electricity  turned  on.  This  mode  of 
handling  premature  infants  has  been  given  thorough  trial  at   the 


Fig.  5.— Electrotherm. 


Babies'  Hospital  and  has  been  found  to  fulfil  the  indications,  with 
children  as  small  as  three  pounds  and  as  young  as  seven  months,  quite 
as  well  as  the  incubator,  while  at  the  same  time  being  free  from  its 
dangers.  It  has  not  been  necessary  to  raise  the  general  tempera- 
ture of  the  room.  These  patients  when  kept  in  the  wards  at  an 
ordinary  temperature  have  maintained  an  even  bodily  temperature 
much  more  uniformly  than  with  any  other  method  I  have  seen,  the 
incubator  included." 

A  mistake  often  made  in  the  management  of  premature  and 
delicate  infants  is  that  of  providing  too  warm  air  for  respiration, 
a  glaring  defect  in  most  incubators.  The  best  means  of  decreasing 
a  delicate  child's  vitahty  and  resistance  and  increasing  his  chances 
of  pulmonary  infection,  is  to  supply  him  constantly  with  air  at 
80°  to  90°  F.  In  a  modern  house  the  maintenance  of  this  temperature 
usually  means  an  absence  of  change  of  air  and  an  abundance  of 


PREMATURE    AND    CONGENITALLY    WEAK    INFANTS 


47 


bacteria.     The  patients  do  best  when  the  temperature  of  the  air 
they  breathe  is  from  70°  to  72°  F. 

Breast-milk  for  premature  infants  born  under  twenty-eight 
weeks  is  almost  a  necessity,  and  should  always  be  procured  when 
possible  for  all  premature  children.  The  mother,  with  the  rarest 
exception,  is  unable  to  supply  it,  so  that  a  wet-nurse  should  be 
secured.  In  selecting  a  wet-nurse  for  a  premature  baby  it  is  advis- 
able to  take  the  wet-nurse's  baby  also,  as  the  premature  infant  may 
not  be  able  to  nurse,  or  if  he  nurses  he  will  not  take  all  the  milk. 
Pumping  the  breasts  of  a  wet-nurse  will  almost  invariably  dry  them 
up,  if  her  own  baby  is  not  with  her  to  furnish  the 
necessary  stimulation  of  nursing.  Sufhcient  milk 
may  be  removed  by  the  breast-pump  to  supply 
the  premature  infant  if  he  is  unable  to  nurse,  and 
the  wet-nurse's  baby  will  empty  the  breast.  For 
premature  babies  who  refuse  the  breast  or  are  un- 
able to  take  a  nipple,  the  Breck  feeder  (Fig.  6) 
may  be  used  as  a  means  of  giving  nourishment, 
or  gavage  (page  135)  may  be  brought  into  use. 
This  I  have  been  obliged  to  resort  to  in  several 
cases.  The  Breck  feeder  consists  of  a  graduated 
glass  tube,  narrowed  at  one  end.  Over  this  end 
is  placed  a  small  rubber  nipple,  the  other  end  being 
closed  by  a  flexible  rubber  cap.  Drawing  on  the 
nipple  is  aided  and  encouraged  by  pressure  on  the 
air-filled  cap.  If  the  breast-milk  proves  too  strong 
it  may  be  diluted  with  equal  parts  of  a  6  percent 
sugar  solution,  from  one-half  to  one  ounce  of  the 
mixture  being  given  at  first  at  intervals  of  from 
one  to  one  and  one-half  hours.  Fourteen  to  fif- 
teen feedings  mav  be  given  in  the  twenty-four 
hours,  the  amount  depending  upon  the  child's  di- 
gestive ability.  If  human  milk  is  not  obtainable, 
whey  made  from  whole  milk  may  be  given,  the  fig.  6.— the  breck 
nutritional  equivalent  of  which  is  approximately  Feeder. 

I  percent  fat,  i  percent  proteid,  5.5  percent 
sugar,  or  one  ounce  of  gravity  cream  may  be  given  with  one  ounce  of 
milk-sugar  and  fifteen  ounces  of  water,  which  gives  a  nutritional 
equivalent  of  i  percent  fat,  5  percent  sugar,  and  3  percent  proteid. 
Canned  condensed  milk,  one  part,  to  from  24  to  30  parts  of  water, 
may  be  used  with  advantage  as  a  temporary  feeding  measure  when 
nothing  better  is  available.  The  food  strength  is  increased,  the 
intervals  made  longer,  and  the  feedings  larger,  as  the  patient  proves 
able  to  assimilate  the  food. 

The  premature  child  requires  unusual  advantages,  and  even  wlien 
but  one  month  premature,  rarely  "catches  up"  during  the  first  year, 
sometimes  not  for  two  or  three  years. 


48  THE    NEW-BORN 


ASPHYXIA  IN  THE  NEWLY  BORN 
The  first  step  in  the  management  of  asphyxia  in  the  newly  born 
iDaby  is  to  clean  the  mouth  and  throat  of  the  mucus  which  will 
almost  invariably  be  found  there.  This  is  best  done  by  using  as 
a  swab  the  index-finger  wrapped  with  dry  absorbent  cotton  or  sterile 
gauze.  Spanking  the  child  or  the  alternate  use  of  a  hot  (iio°  F.) 
and  cold  (60°  F.)  bath,  the  child  being  rapidly  transferred  from  one 
to  the  other,  will  often  stimulate  respiration  by  inducing  the  child 
to  cry.  When  these  methods  fail,  inflation  of  the  lungs  by  the 
mouth-to-mouth  method  may  be  attempted.  Various  other  methods 
of  inducing  respiration  have  been  advocated  from  time  to  time. 
The  most  effective  are  those  of  Laborde,  Dew,  and  Schultze.  The 
Laborde  method  consists  in  making  rhythmic  traction  on  the  tongue, 
from  twelve  to  fourteen  times  a  minute,  which  it  is  claimed  excites 
respiration.  The  Dew  method  consists  in  grasping  the  infant  by 
the  back  of  the  neck  Avith  one  hand  and  by  the  knees  with  the  other. 
The  upper  and  lower  portions  of  the  child  are  then  approximated 
by  a  flexion  of  the  thorax  on  the  abdomen ;  the  reverse  movement — 
extension — should  also  be  used,  and  thus  alternate  flexion  and 
extension  are  practised  fifteen  to  twenty  times  a  minute.  Schultze's 
method  is  described  by  him  and  quoted  by  Edgar  as  follows :  ' '  The 
child  lying  upon  its  back  is  grasped  by  the  shoulders,  the  open  hand 
having  been  slipped  beneath  the  head.  The  last  three  fingers 
remain  extended  in  contact  with  the  back  while  each  index-finger 
is  inserted  into  an  axilla,  the  thumbs  lying  upon  and  in  front  of  the 
shoulders.  When  the  child  thus  held  is  allowed  to  hang  suspended, 
its  entire  v/eight  rests  upon  the  two  fingers  in  the  arm-pits.  It  is 
now  swung  forward  and  upward,  the  operator's  hands  going  to  the 
height  of  his  own  head ;  the  pelvic  end  of  the  child  rises  above  its 
head  and  falls  slowly  toward  the  operator  by  its  own  weight,  flexion 
occurring  in  the  lumbar  region.  The  thumbs  in  front  of  the  shoulders 
compress  the  chest  while  the  hyperflexed  lumbar  vertebrae  and 
pelvis  compress  the  abdomen  and  through  it  the  thorax;  finally, 
the  last  three  fingers  on  each  side  compress  the  thorax  laterally. 
As  a  result  of  this  manoeuver,  when  properly  done,  aspirated  secre- 
tions flow  abundanth'  from  the  mouth.  The  distended  heart  also 
feels  the  compression  which  forces  the  blood  into  the  arteries.  The 
child  is  now  swung  back  into  its  original  position  and  supported 
entirely  by  the  fingers  in  the  axillae.  The  compression  of  the  thumbs 
and  last  three  fingers  is  removed.  The  downward  swing  elevates 
the  sternum  and  ribs,  while  gravitation  and  the  traction  of  the 
intestines  depress  the  diaphragm.  It  is  often  possible  to  hear  the 
air  rush  into  the  infant's  glottis  as  it  reaches  the  original  position, 
although  this  can  occur  in  a  cadaver.  The  amplification  of  the 
thorax    lowers    the    intracardiac    pressure.     The    child    should    be 


SEPSIS    IN    THE    NEWLY  BORN  49 

swung  Up  and  down  ten  times  for  the  space  of  a  minute.  The 
effects  of  the  manoeuver  should  be  as  follows:  The  heart-beat 
increases  in  frequency,  the  cadaveric  pallor  of  the  jikin  becomes 
replaced  by  a  rosy  hue,  and  the  muscular  tonus  appears.  The  child 
is  then  placed  in  a  warm  bath  and  watched.  If  the  inspirations  are 
superficial,  a  momentary  dip  in  cold  water  is  indicated.  If  the 
heart-action  becomes  poor  the  child  should  be  swung  again.  If 
prolonged  swinging  becomes  necessary,  the  root  of  the  tongue  should 
be  compressed  forward  in  order  to  raise  the  epiglottis  and  permit 
the  removal  of  secretions  with  the  fingers.  In  premature  children 
the  thoracic  walls  are  often  too  soft  to  benefit  by  the  compression 
of  the  fingers.  In  these  cases  insufflation  of  air  should  be  practised." 
It  is  not  well  to  rely  upon  one  method.  If  necessary,  different 
means  of  inducing  respiration  may  be  attempted  in  a  given  case. 
The  introduction  of  a  catheter  or  instruments  into  the  larynx  has 
not  met  with  favor  from  obstetricians. 

SEPSIS  IN  THE  NEWLY  BORN 

The  newly  born  infant  is  peculiarly  susceptible  to  infections, 
particularly  with  the  pyogenic  bacteria.  The  avenues  for  the 
entrance  of  bacteria  into  the  body  are  many,  and  the  resistance  at 
this  period  of  life  is  very  slight.  Infection  may  be  either  through  the 
mouth,  which  is  probably  the  most  frequent  portal  of  entry,  or 
through  the  nose,  the  skin,  the  rectum,  the  conjunctivae,  the  urethra, 
the  umbilicus,  and,  in  girls,  the  vagina.  Almost  any  portion  of  the 
body  may  be  the  seat  of  the  infection.  It  is  rare,  according  to  the 
cases  upon  which  I  have  made  autopsies,  to  find  only  one  organ  or 
structure  affected.  Usually  two  or  three  or  more  portions  of  the 
body  are  involved  in  the  septic  process. 

The  management  resolves  itself  into  relieving  the  system  of  the 
infection,  as  is  possible  when  its  seat  of  operation  is  the  skin  in  mul- 
tiple abscess  formation ;  incision  should  be  made  and  followed  by  a  wet 
dressing  of  a  saturated  solution  of  boric  acid,  or,  if  the  area  is  not  too 
large,  a  1 15000  solution  of  bichlorid.  If  the  site  of  the  infection  is  at 
the  umbilicus,  the  suppurating  surface  should  be  thoroughly  cleansed 
and  kept  covered  with  a  wet  dressing  of  i  :  5000  bichlorid,  which 
should  be  changed  at  least  every  two  hours.  If  there  is  erysipelas, 
an  ointment  composed  of  30  percent  ichthyol  in  vaselin  makes  the  best 
dressing.  This  should  be  freshly  applied  every  four  hours.  The  septic 
infant,  whether  the  infection  is  mild  or  severe,  usually  nurses  very 
poorly.  Oftentimes  both  breast  and  bottle  are  refused.  When  a 
sufficient  amount  of  fluid  is  not  taken,  plain  boiled  water  or  sugar- 
water,  5  per  cent,  or  completely  peptonized  skimmed  milk,  may  be 
given  by  gavage.  If  fluids  are  not  given,  the  child  is  very  apt  to  de- 
velop inanition  fever,  which,  added  to  the  infection,  makes  a  serious 
condition  more  serious.  From  two  to  four  ounces  of  a  normal  salt 
4 


50  .  THE    NEW-BORN 

solution  used  lukewarm,  injected  into  the  descending  colon  through 
a  catheter,  will  often  be  retained  with  beneficial  results.  It  should 
not  be  repeated  oftener  than  once  in  six  hours. 

Medication  other  than  small  doses  of  alcohol — five  drops  of 
brandy,  well  diluted,  every  hour  if  necessary — has  been  without 
avail  in  my  cases.  The  prognosis  at  best  is  very  grave,  although 
when  the  vital  organs  are  not  involved,  cases  occasionally  recover. 

An  unusual  case  of  infection  which  ended  in  recovery  occurred 
in  my  private  practice.  The  child  had  no  fever,  but  lost  rapidly 
in  weight.  There  was  marked  prostration.  The  skin  took  on  a 
greenish  hue  and  we  were  at  a  loss  to  discover  the  cause  of  the  illness. 
The  infection  was  suspected,  but  no  portal  of  entry  could  be  found, 
neither  could  we  find  any  localized  process  until  the  nurse  discovered 
that  the  umbilicus  and  the  skin  about  it  were  bathed  in  pus.  The 
umbilicus  had  apparently  healed  without  any  indication  of  local 
trouble.  Investigation  showed,  however,  that  the  infection  had 
entered  at  this  site,  and  extending  along  the  vein  or  artery,  had 
become  pocketed  and  formed  an  abscess  one  and  one-half  inches 
deep.  Enlarging  the  opening  at  the  umbilicus  and  establishing 
free  drainage  were  followed  by  a  gradual  closure  of  the  abscess 
cavity  and  recovery. 

CEPHALHEMATOMA 

A  cephalhematoma  is  a  blood  tumor  situated  between  the  peri- 
cranium and  the  exterior  of  one  or  more  of  the  bones  of  the  skull. 
The  tumors  vary  considerably  in  size,  are  readily  recognized,  and  are 
situated  at  the  site  of  the  caput  succedaneum.  In  a  small  proportion 
of  the  cases  an  internal  tumor  occurs  at  the  same  time,  the  effusion 
taking  place  between  the  dura  mater  and  the  skull.  Very  rarely 
suppuration  occurs  in  the  tumor.  I  have  seen  two  cases  of  this 
nature,  both  of  which  recovered  under  incision  and  antiseptic  dress- 
ings. If  there  is  an  internal  effusion  the  case  will  be  fatal.  One  of 
these  has  come  under  my  observation.  The  usual  course,  when  the 
tumor  is  external,  is  for  it  to  be  absorbed  without  treatment. 

ICTERUS  NEONATORUM 
Jaundice  occurs  in  about  one-third  of  all  infants.  It  usually 
makes  its  appearance  on  the  second  or  third  day  and  lasts  from  a 
few  days,  in  mild  cases,  to  a  week  or  ten  days,  in  severe.  Its  effect 
on  the  child  is  practically  nil.  At  the  New  York  Infant  Asylum 
the  records  show  that  the  icteric  infants  thrive  as  well  as  those  who 
are  entirely  free  from  the  complaint.  It  is  well  in  these  infants  to 
keep  the  intestinal  tract  active.  If  the  bowels  do  not  move  freely, 
twenty  drops  of  castor  oil  should  be  given  and  repeated  in  twenty-four 
hours,  if  required. 


UMBILICAL    POLYP ATELECTASIS  5 1 


UMBILICAL  POLYP 
An  umbilical  polyp  is  usually  the  result  of  an  overgrowth  or  an 
outgrowth  of  a  neglected  granuloma.  The  mass,  which  may  vary 
in  size  from  a  flaxseed  to  a  pea,  is  reddened,  moist,  and  usually 
bathed  in  a  viscid  muco-purulent  secretion.  There  is  often  con- 
siderable excoriation  of  the  skin  about  the  umbilical  opening. 
Sometimes  the  mass  is  so  small  that  it  is  hidden  by  the  overlapping 
folds  of  skin,  and  its  presence  would  not  be  suspected  but  for  the 
secretion  which  keeps  the  parts  moist.  The  polypi  are  very  vascular. 
Cutting  the  pedicle  and  applying  nitrate  of  silver  or  carbolic  acid  is 
not  a  safe  procedure.  I  have  known  severe  hemorrhage  to  follow 
such  treatment.  About  ten  years  ago  I  was  obliged  to  sit  for  three 
hours  by  the  side  of  a  crying,  wriggling  child  making  pressure  on  the 
cut  stump  of  an  umbilical  polyp,  after  a  colleague  had  cut  the  pedicle. 
In  no  other  way  could  the  hemorrhage  be  controlled.  The  best 
means  of  management  in  these  cases  is  to  ligate  the  pedicle  and 
allow  the  polyp  to  wither  and  drop  off.  The  powder  referred  to 
under  the  head  of  Granuloma  should  be  applied  after  the  ligature 
is  fixed,  and  reapplied  frequently  before  and  after  the  polyp  has 
dropped  off,  and  continued  until  the  wound  is  cicatrized  and  dr\\ 

ATELECTASIS 

Atelectasis  may  be  present  in  the  newly  born  who  come  into  the 
world  asphyxiated,  and  it  is  not  infrequently  seen  when  there  has 
been  a  prolonged  difficult  delivery.  It  may  be  the  result  of  weak- 
ness, pure  and  simple,  and  is  not  of  unusual  occurrence  in  the  pre- 
mature. For  some  reason  there  is  a  failure  or  inability  to  dilate  the 
air-vesicles.  I  have  seen  sudden  collapse  occur  in  marantic  infants, 
the  child  dying  in  a  few  moments  with  cyanosis  and  orthopnea, 
the  autopsy  proving  the  diagnosis  of  atelectasis.  The  condition 
may  be  produced  also  through  compression  of  the  lung  with  exuda- 
tion in  pleurisy  or  by  the  obstruction  of  a  bronchus  with  mucus. 
The  most  dangerous  types  are  those  in  which  it  is  present  in  the 
newly  born  and  when  it  occurs  in  the  weakly  during  early  life.  The 
warning  of  its  presence  is  usually  in  the  form  of  cyanosis  with  rapid 
superficial  breathing  with  or  without  convulsions. 

The  management  of  atelectasis  in  the  newly  bom,  who  come  into 
the  world  asphyxiated  because  of  prolonged  difficult  delivery  or 
when  it  is  the  result  of  weakness,  is  to  make  the  child  cry  lustily. 
If  auscultation  over  the  lower  lobes  posteriorly  does  not  show  free 
vesicular  breathing,  the  child  should  be  made  to  cry  every  day, 
either  by  spanking,  or  by  plunging  him  first  into  water  at  1 10°  F.  and 
again  into  cold  water  at  60°  F.,  our  object  being  to  induce  vigorous 
crying  and  thus  dilate  the  air-vesicles.  A  case  under  treatment  at 
the  present  time  is  making  satisfactory  improvement  by  inhaUng 


52  THE    NEW-BORN 

oxygen  for  one  minute  out  of  every  fifteen,  with  stimulation  of 
various  kinds  to  make  him  cry.  Atelectasis  from  obstruction  of  a 
bronchus  or  from  compression  is  usually  readily  relieved  when  the 
source  of  the  trouble  is  removed.  In  out-patient  work  we  occa- 
sionally see  marantic  young  infants  in  which  there  is  an  involve- 
ment of  a  considerable  area  of  one  of  the  lower  lobes  posteriorly 
without  any  sign  whatever  of  discomfort.  The  process  of  resolution 
in  these  cases  is  very  slow,  from  the  periphery  toward  the  center. 
The  condition  is  probably  of  much  more  frequent  occurrence  than 
is  generally  supposed,  if  we  are  to  judge  from  the  autopsy  findings 
in  young  infants,  particularly  in  institutions. 

MASTITIS  IN  THE  NEWLY  BORN 
Inflammation  of  the  breasts  in  the  newly  born,  both  in  the  male 
and  in  the  female,  is  seen  with  considerable  frequency  in  out-patient 
work.  The  mammary  glands  may  be  swollen  to  several  times  their 
normal  size  and  acutely  tender.  These  glands,  in  young  infants, 
should  not  be  pressed  or  manipulated  in  any  way,  more  than  is 
required  for  cleanliness.  Not  a  few  of  my  out-patient  cases  of 
mastitis  have  been  due  to  the  attempts  of  the  midwife  to  express 
the  milk  from  the  breasts.  The  cases  are  explained  by  the  fact 
that  the  opening  of  the  nipple  is  large  and  the  gland  readily  becomes 
infected  from  unwashed  hands  or  unclean  wearing  apparel.  My 
cases  have  usually  responded  well  to  the  application  of  ichthyol 
25  percent  in  oxid  of  zinc  ointment,  U.  S.  P.  The  ointment  is 
spread  generously  upon  old  linen,  which  has  been  boiled  and  dried, 
and  is  then  gently  bound  upon  the  inflamed  gland.  Over  this  is 
placed  oiled  silk  to  protect  the  clothing,  and,  over  all,  a  gauze 
bandage  is  applied  with  very  light  pressure.  The  dressing  should 
be  changed  and  fresh  ointment  applied  every  six  hours.  In  four 
of  my  cases  the  mastitis  was  beyond  control  when  first  seen  and 
suppuration  of  the  gland — mammary  abscess — followed. 

Mastitis  in  Young  Girls. — Inflammation  of  the  mammary 
gland  in  young  girls  is  a  comparatively  rare  condition,  but  one  of 
sufficiently  frequent  occurrence  to  require  mention.  Swelling  and 
tenderness  of  the  breasts  are  often  complained  of  by  young  girls 
about  the  time  of  puberty,  but  they  subside  without  treatment  if 
let  alone.  Mastitis  is  usually  due  to  the  entrance  of  bacteria  through 
the  nipple,  and  in  its  clinical  manifestations  it  resembles  mastitis 
in  the  adult,  except  that  the  entire  gland  is  usually  involved,  becom- 
ing swollen,  tender,  and  excruciatingly  painful.  Two  of  these  cases 
have  been  under  my  care  during  the  past  year ;  one  in  a  girl  of  thirteen, 
the  other  in  a  girl  of  seven  years.  Both  cases  responded  to  the  use 
of  an  ice-bag  during  the  acute  stage,  which  was  kept  constantly 
applied  during  the  waking  hours.  At  night  a  wet  dressing  of  bichlo- 
rid  of  mercury,    i :  5000,   was  kept  on  the  infected  glands.     There 


HEMORRHAGIC    DISEASES    OF    THE    NEWLY  BORN 


53 


was  moderate  fever,  headache,  and  lassitude  in  both  patients.  Each 
was  given  a  saline  laxative  in  the  form  of  citrate  of  magnesia,  and 
a  diet  of  broth,  gruel,  toast,  and  stewed  fruit.  This  diet  was  con- 
tinued during  the  period  of  fever.  In  one  case  recovery  occurred 
in  five  days  and  in  the  other  in  seven  days. 

Mammary  Abscess  in  Infants.— Mammary  abscess  is  the  result 
of  a  mastitis  which  failed  to  undergo  resolution.  It  occurs  as  fre- 
quently in  males  as  in  females.  All  of  my  cases  were  seen  in 
institutions  or  in  out-patient  work.  In  four,  the  abscess  developed 
under  my  own  observation.  In  a  female  child,  a  patient  at  the 
New  York  Infant  Asylum,  both  glands  were  entirely  destroyed. 
As  soon  as  pus  is  discovered  the  abscess  should  be  incised  and 
drained,  with  a  view  to  saving  as  much  of  the  gland  as  possible. 
Of  course,  this  advice  applies  particularly  to  a  female  patient.  Wet 
dressings  are  not  applicable  in  cases  of  young  infants  when  the  parts 
covering  the  thorax  or  abdomen  are  involved.  It  is  my  custom  to 
protect  the  skin  from  infection  by  the  use  of  a  lo  percent  boric 
acid  ointment  in  cold-cream  as  a  base.  This  is  applied  on  old  linen 
about  the  abscess  opening.  The  dressing  should  be  changed  three 
times  daily. 

UMBILICAL  GRANULOMA 

A  granuloma  at  the  umbilicus  consists  of  a  reddish  secreting 
mass  of  granulations  comprising  the  umbilical  stump.  It  may 
vary  in  size  from  the  head  of  a  pin  to  a  pea.  Granulomata  usually 
occur  in  cases  in  which  the  care  of  the  cord  has  been  neglected. 
In  out-patient  work  they  are  very  frequently  seen,  and  occur  usually 
in  children  who  have  been  delivered  by  midwives.  The  mother 
brings  the  child  to  the  dispensary  with  the  story  that  the  navel 
will  not  heal. 

The  granulations  are  very  vascular  and  bleed  readily.  After 
thoroughly  cleansing  the  parts,  one  or  more  applications  of  a  50  per- 
cent nitrate  of  silver  solution,  followed  by  the  free  use  of  an  absorbent 
dusting-powder,  soon  produces  a  normal  cicatrix.  A  powder  of 
the  following  composition  is  recommended : 

I^.     Acidi  salicylici gr.  xv 

Acidi  borici gr.  xxv 

Pulveris  zinci  oxidi 

Pulveris  amyli aa  5  j 

The  powder  should  be  applied  very  freely  at  two-hour  intervals 
during  the  day,  or  at  least  often  enough  to  keep  the  wound  dry. 

HEMORRHAGIC  DISEASES  OF  THE  NEWLY  BORN 
A  considerable  number  of  these  infants  have  come  under  my 
observation  at  the  New  York  Infant  Asylum.     In  describing  the 
condition    it    would    seem    unnecessary   to    continue    an   irrational 


54  THE    NEW-BORN 

nomenclature  still  in  use,  based  upon  the  location  of  the  hemorrhage, 
or  the  name  of  the  physician  who  is  believed  to  have  given  the  first 
description  of  a  symptom-complex  which  is  supposed  to  characterize 
the  disease.  I  have  seen  hemorrhages  in  the  newly  born  occur  from 
nearly  every  portion  of  the  body  and  into  most  of  the  internal  organs. 
In  a  recent  case  a  colored  infant  bled  to  death  in  the  pericranial 
tissues  without  a  sign  of  hemorrhage  elsewhere.  I  have  seen  fatal 
hemorrhages  from  the  navel  which  we  were  not  able  to  control. 
vSyphilis  and  hemophilia  play  an  insignificant  part  in  causing  the 
hemorrhage.  Sepsis  is  a  broad  term  that  covers  the  etiology  of 
these  cases.  Oftentimes  there  are  other  proofs  of  the  infection 
aside  from  the  hemorrhage.  Because  infections  differ  in  degree, 
nature,  and  field  of  action  does  not  necessarily  call  for  a  typical 
description  of  each  form  of  infection,  and  with  our  limited  knowledge 
of  the  infectious  process  which  may  cause  the  hemorrhage,  this  is 
impossible  at  the  present  time.  Without  doubt  different  forms  of 
infection  may  enter  the  circulating  medium  of  the  newly  born  with 
a  result  in  hemorrhage.  The  cases  resemble  hemophilia  in  the 
persistence  of  the  bleeding,  while  infrequently  disproving  its  exis- 
tence by  making  a  complete  recovery.  The  use  of  styptics  and 
astringents  for  controlling  the  hemorrhage  is  useless.  The  only 
measure  that  has  assisted  me  in  any  way  has  been  the  application 
of  pressure  to  the  bleeding  parts,  and  this  is  not  possible  in  many 
situations.  Adrenalin,  locally  or  by  internal  administration,  has 
not  been  of  any  appreciable  service.  Our  best  results,  which  were 
by  no  means  satisfactory,  were  obtained  by  attention  to  the  gastro- 
enteric tract  and  in  supplying  the  best  possible  means  of  nutrition. 

TETANUS  NEONATORUM 

Tetanus  in  the  young  infant  is  fortunately  of  very  infrequent 
occurrence.  From  the  second  to  the  ninth  day  is  the  usual  period 
of  the  development  of  the  disease,  although  it  may  appear  as  late 
as  the  fourth  or  fifth  week.  Recovery  is  the  exception.  But  few 
cases  live  longer  than  the  second  day  of  the  illness.  The  treatment 
is  by  the  use  of  sedatives  such  as  chloral  and  the  bromids.  One 
grain  of  chloral  every  two  hours  appears  to  exert  some  temporary 
benefit.  Targe  doses  of  bromid  of  soda— eight  to  ten  grains — ad- 
ministered by  the  rectum  every  three  hours  in  mucilage  of  acacia 
have  given  good  results  according  to  some  observers.  Tetanus  anti- 
toxin has  not  been  used  in  a  sufficient  number  of  cases  to  establish 
any  facts  relating  to  its  value.  The  nutrition  of  the  patient  is  best 
maintained  by  the  use  of  peptonized  milk  given  by  gavage. 

The  cord  stump  should  be  cauterized  in  order  to  destroy  any 
tetanus  bacilli  which  may  be  present  and  a  wet  dressing  of  i :  5000  of 
bichlorid  of  mercury  kept  constantly  applied. 


NUTRITION  AND  GROWTH 

The  fundamental  principles  in  the  life  of  the  young  of  all  animals 
are  growth  and  development.  This  statement  applies  to  the  young 
of  the  lower  animals  as  well  as  to  man.  Nature  has  fixed  and 
definite  laws  in  accordance  with  which  this  growth  and  development 
proceed.  The  type  of  animal  produced  depends  in  no  small  degree 
upon  the  way  we  follow  out  Nature's  laws. 

Heredity  is,  of  course,  an  important  factor,  but  environment 
counts  for  more.  The  young  of  the  lower  animals  or  of  man  may 
possess  all  that  can  be  desired  in  the  way  of  heredity,  but  if  the 
later  management  of  his  life  is  faulty,  an  adult  is  produced  which  is 
almost  certain  to  fall  short  of  the  normal.  On  the  other  hand, 
another,  without  the  benefits  of  a  good  heredity,  when  given  the 
advantages  of  faithful  scientific  care  may  produce  an  adult  decidedly 
superior  in  all  respects  to  those  more  fortunate  in  birth.  I  have 
seen  this  demonstrated  time  and  again,  both  in  the  lower  animals 
and  in  man.  From  my  earliest  recollection  I  have  carefully  watched 
the  growth  and  development  of  animals.  By  observing  care  as  to 
feeding,  housing,  ventilation,  cleanliness,  and  exercise,  I  have  seen 
animals  which  promised  but  little  at  birth  develop  into  perfect 
mature  specimens  of  their  kind.  During  the  past  eighteen  years 
I  have  been  intimately  associated  with  thousands  of  infants  and 
growing  children  in  private,  in  hospital,  and  in  out-patient  work. 
The  possibilities  of  proper  growth  under  good  management  when 
little  was  to  be  expected,  judging  from  the  original  condition  of  the 
patient,  have  been  impressed  upon  me  repeatedly. 

The  child  is  here  through  no  choice  of  his  own.  He  is  to  have 
a  future.  His  health,  vigor,  powers  of  resistance,  happiness,  and 
usefulness  as  a  citizen  are  determined  in  no  small  degree  by  the 
nature  of  his  care  during  the  first  fifteen  years  of  life.  He  has  a 
right  to  demand  that  such  care  be  given  him  as  will  be  conducive 
at  least  to  a  sound,  well-developed  body,  and  this  should  be  our 
first  thought  and  object  regarding  him.  Consider  for  a  moment  the 
number  of  occupations,  other  than  the  army  and  the  navy,  which 
require  physical  fitness  before  a  candidate  is  accepted.  Competi- 
tion is  keen  at  the  present  time  and  will  be  keener  in  the  future. 
Employers  of  men  and  women,  whether  in  the  office,  the  factory,  or 
on  the  farm,  cannot  afford  to  employ  the  physically  weak. 

The  most  important  factor  in  the  making  of  men  and  women  is 
nutrition.  It  requires  no  great  power  of  reasoning  to  appreciate 
the  fact  that  the  child  who  is  fed  on  suitable  food  will  become  a 

55 


56  NUTRITION   AND   GROWTH 

more  vigorous,  better  developed  adult  than  one  who,  beginning  with 
his  birth  and  continuing  throughout  the  entire  period  of  his  growth, 
is  given  only  food  possessing  indifferent  tissue-building  qualities. 
Next  in  importance  to  food,  and  following  in  close  succession,  are 
fresh  air,  cleanliness,  cheerful  surroundings,  and  healthful  amuse- 
ments, together  with  an  absence  of  work  of  an  arduous  nature, 
whether  in  school  or  at  service.  That  the  offspring  of  man  suffers 
more  from  nutritional  errors  due  to  the  lack  of  suitable  care  than  do 
the  young  of  the  lower  animals  is  lamentable,  but  it  is  a  fact  never- 
theless. The  absence  of  thought  and  care  and  of  knowledge  relating 
to  children  is  due  to  the  fact  that  the  child  as  such  has  apparently  no 
intrinsic  value  in  dollars  and  cents,  whereas  the  young  of  the  lower 
animals  are  no  small  part  of  their  owner's  material  possessions. 

Success  in  the  management  of  children,  nutritionally  and  other- 
wise, means  daily  attention  to  detail.  Feeding  the  child  properly 
one  or  two  months  out  of  the  year  is  of  little  value.  He  should  be 
fed  properly  every  day  in  the  year,  for  under  normal  conditions 
every  day  is  a  day  of  growth.  Another  factor  having  a  deterrent 
influence  upon  the  development  of  children  is  their  unfavorable 
start  during  the  first  year.  Unfortunately  many  mothers  cannot 
supply  to  the  infant  the  nourishment  to  which  he  is  entitled,  and  this 
brings  us  to  the  matter  of  substitute  feeding,  fraught  with  its  per- 
plexities and  uncertainties  in  the  most  competent  hands,  and  with  its 
dangers  and  disasters  with  the  incompetent  and  inefificient.  In  the 
chapter  on  Substitute  Feeding  in  infants  their  nutrition  is  consid- 
ered in  detail.  It  is  sufficient  to  remark  here  that  Nature  has 
provided  for  the  baby  a  food  which  contains  the  nutritional  elements, 
fat,  sugar,  and  proteid,  in  fairly  definite  proportions  and  in  peculiar 
forms.  Success  in  substitute  feeding  depends  upon  our  ability  to 
supplv  in  suitable  forms,  and  the  child's  ability  to  assimilate,  a  food 
containing  approximately  the  quantities  of  the  nutritive  elements 
found  in  human  milk.  An  exact  reproduction  of  mother's  milk  by 
the  use  of  cow's  milk  or  other  food  is,  of  course,  impossible,  ^^'e  can 
imitate  it,  however,  with  sufficient  accuracy  to  make  it  an  acceptable 
and  sufficient  food  for  most  children  who  are  deprived  of  the  breast. 
Mtev  the  nursing  or  the  bottle  age,  the  feeding  must  not  be  left  to 
the  family  judgment,  for  at  this  rapidly  growing  period  suitable 
nutrition  is  most  important.  Left  to  the  family,  the  diet  during 
the  second  year  is  very  apt  to  consist  of  milk,  which  in  large  cities 
is  often  of  uncertain  nutritive  value,  together  w4th  insufficiently 
cooked  cereals,  boxed  breakfast  foods,  bread-stuffs,  crackers,  and 
cake^often  procured  at  the  grocer's  or  baker's.  At  the  out-patient 
departments  of  the  New  York  Babies'  Hospital  and  the  New  York 
Polyclinic  Medical  School  only  20  percent  of  the  children  treated 
who  are  over  one  year  of  age  are  of  normal  development.  In  those 
under  one  year  of  age,  only  35  percent  are  normal.     \\'hile  these 


NUTRITION    AND    GROWTH  57 

children  are  not  to  be  considered  as  representing  the  country  as  a 
whole,  still  they  do  represent  a  large  part  of  the  population  of  our 
larger  cities.  These  children  are  the  offspring  of  day-laborers, 
drivers,  waiters,  and  small  wage  earners  generally.  They  have 
been  fed  in  the  manner  above  described,  not  because  of  poverty,  but 
because  of  an  absence  of  the  slightest  knowledge  on  the  part  of  the 
parents  regarding  suitability  of  foods.  Their  children  were  not 
hungry,  they  were  fed  to  satisfy  the  appetite,  but  when  that  was 
accomplished  the  parents  considered  their  duty  done.  To  feed  with 
a  definite  purpose — with  a  view  solely  to  the  physical  development 
of  their  children — had  never  entered  the  minds  of  the  parents,  yet 
most  of  them  could  read  and  write  and  possessed  a  fair  degree  of 
general  intelligence.  They  were  conversa'nt  with  affairs  and  had 
attended  the  public  schools,  but  were  absolutely  untaught  as  to  how 
they  should  live. 

The  diet  during  this  period  of  child  life  should  be  highly  nutritious, 
and,  in  order  to  be  properly  digested,  food  should  be  given  at  definite 
intervals.  The  habit  of  allowing  children  to  eat  between  meals 
cannot  be  too  strongly  condemned.  It  not  only  spoils  the  appetite 
for  suitable  food  at  regular  hours,  causing  children  to  crave  delicacies, 
but  prevents  the  most  complete  digestion  and  assimilation.  The 
active  "runabout"  child  and  the  school-child  require  a  high  proteid 
diet.  It  should  consist  of  red  meat,  never  oftener  than  once  daily, 
poultry,  fish,  eggs,  milk,  butter,  cream,  whole-wheat  bread  and 
cereals,  such  as  oatmeal,  cracked  wheat,  commeal,  and  hominy. 
Other  cereals  may  be  used  for  the  sake  of  variety.  Each  cereal 
mentioned  should  be  cooked  three  hours  the  day  before  using. 
It  may  be  claimed  that  the  prolonged  cooking  is  impossible  to  secure. 
It  is  done,  however,  in  dozens  of  families  under  my  professional 
care.  Green  vegetables  and  stewed  and  raw  fruits  are  important 
adjuncts  to  the  dietary.  Dried  peas,  beans,  and  lentils  in  the  form 
of  a  puree,  are  valuable  articles  of  nutrition  because  of  their  large 
percentages  of  vegetable  proteid,  and  they  are  particularly  useful 
in  children  with  a  rheumatic  tendency,  in  whom  the  use  of  red  meat 
must  be  curtailed. 

Doubtless  the  next  most  important  factor  after  food  and  the 
means  of  giving  it,  is  good  air.  It  is  a  just  criticism  of  the  average 
American  that  he  is  afraid  of  fresh  air,  not  only  by  night  but  by  da}^ 
and  it  is  one  of  the  most  difficult  features  of  a  child's  management 
with  which  I  have  had  to  deal.  Mothers  will  feed  the  children  in 
detail  according  to  instruction.  They  will  bathe  them  and  follow 
out  to  my  satisfaction  every  order  and  direction.  The  stumbling- 
block  is  the  open  window.  If  the  mother  opens  it  as  directed,  the 
grandmother  or  some  other  member  of  the  family  appears  on  the 
scene  and  closes  it.  The  window-board  (page  43)  and  other  means 
of  ventilation  on  the  market  have  their  uses.     The  window-board  in 


58  NUTRITION    AND    GROWTH 

my  hands  has  been  most  satisfactory.  It  is  to  be  hoped  that  a 
knowledge  of  the  means  and  results  of  treating  tuberculosis  by 
open-air  methods,  and  the  recent  agitation  concerning  the  treatment 
of  pneumonia  and  other  infectious  diseases  along  similar  lines,  may 
so  permeate  the  minds  of  the  masses  as  to  quiet  their  fears  regarding 
dangers  of  outdoor  air. 

In  my  own  experience  I  have  been  able  to  secure  an  ample  supply 
of  fresh  air  either  by  the  window-board,  already  referred  to,  or  the 
open  fireplace.  When  the  ehild  is  out  of  the  liying-room  or  nursery, 
the  room  is  ventilated  by  opening  all  the  windows,  when  family 
conditions  allow,  the  nursery  always  being  aired  in  this  way.  The 
sleeping-room  should  always  be  aired  for  one  hour  before  the  child  is 
put  to  bed.  Indoor  airing  (page  37),  for  which  the  child  is  dressed 
as  for  going  out,  placed  in  his  carriage  or  cart,  and  wheeled  up  and 
down  the  room  for  an  hour  or  two  with  the  windows  wide  open 
regardless  of  the  weather,  is  most  satisfactory  in  very  young  and  very 
delicate  children,  and  during  convalescence  from  illness.  On  very 
inclement  days  the  child  accustomed  to  his  daily  outing  will  be  greatly 
benefited  by  the  indoor  airing. 

With  bathing  we  have  less  to  complain  of.  The  necessity  for  the 
daily  bath  is  appreciated  and  acted  upon  by  nearly  all  classes  of 
society.  From  the  time  the  cord  falls  and  the  cicatrix  forms,  the 
well  infant  and  child  should  have  one  tub-bath  daily.  If  he  is  too 
ill  for  the  tub,  he  is  not  too  ill  to  be  sponged.  The  well  child  is 
naturally  good-natured  and  happy.  When  such  is  not  the  case, 
we  have  not  a  well  child  to  deal  with.  Something  is  wrong.  Often- 
times it  is  the  home  management.  Adults  often  forget  that  exuber- 
ance of  spirits  and  thoughtlessness  belong  to  childhood.  Persistent 
child-nagging  becomes  a  habit  with  many  parents  and  teachers; 
in  fact,  irritable  mothers  usually  have  irritable  children.  Work 
involving  strain,  whether  physical  or  mental,  should  form  no  part 
of  the  life  of  the  child.  In  our  modern  school  system  the  forcing 
process,  the  competitions,  the  giving  of  rewards  of  merit,  are  all  of 
them  pernicious  practices.  As  a  result  of  the  competitive  system, 
progress,  to  be  sure,  is  made  along  intellectual  lines,  but  at  the 
expense  of  the  physical,  and  what  does  intellectual  attainment  count 
for  in  a  weakly  or  diseased  body?  A  child  cannot  do  hard  mental 
work,  such  as  is  required  of  many  children  from  the  tenth  to  the 
fifteenth  year,  and  be  expected  at  the  same  time  to  develop  to  the 
best  advantage  physically.  The  appetite  and  digestive  powers,  the 
capacity  for  taking  and  assimilating  food,  are  diminished  as  a  result. 
I  have  seen  it  in  hundreds  of  cases.  On  the  streets  in  New  York 
two  pictures  always  fill  me  with  pity — one  is  the  pale,  slender  school- 
girl struggling  home  with  a  load  of  books.  Such  a  child  who  came 
to  me  during  the  past  year  had  eleven  text-book  studies  besides 
piano  and  dancing  lessons!     When  the  question  is  asked  the  child 


GENERAL   PROPERTIES   OF   FOODS  59 

or  the  parents  as  to  the  why  of  all  this  work  and  worry  and  the  close 
confinement  which  it  entails,  the  reply  almost  invariably  is  that  all 
the  girls  of  her  age  do  the  same  and  she  does  not  want  to  be  behind. 
The  other  picture  is  the  "little  mother," — a  pale,  wan,  tired  child 
from  seven  to  twelve  years  of  age  who  "minds  the  baby"  and  the 
other  younger  members  of  the  household  while  their  mother  is  away 
from  home  or  at  work.  Children  so  abused  are  happily  growing 
fewer,  owing  to  various  factors  which  need  not  be  discussed  here. 
It  is  needless  to  say  that  neither  type  of  child  makes  the  ideal  woman 
or  mother  in  any  station  in  life.  The  condition  of  boys  who  work 
in  factories,  sweat-shops,  or  elsewhere  is  no  better.  When  too 
much  energv  is  expended  in  work,  it  cannot  go  to  the  building  up  of 
a  strong  normal  body.  The  State  is  the  loser  and  the  child  is  robbed 
of  his  birthright. 

It  is  the  duty  of  physicians  having  children  under  their  care  to 
explain  in  detail  to  parents  their  responsibility  as  regards  the  physical 
welfare  of  their  children.  Parents,  as  a  rule,  are  ignorant  as  to  a 
child's  management;  but  they  are  anxious  and  wilhng  to  do  the 
best  things  possible  for  their  children,  and  will  carry  out  suggestions 
if  we  take  the  trouble  to  enlighten  them  as  to  their  errors. 

GENERAL  PROPERTIES  OF  FOODS 

Substances  used  as  foods,  regardless  of  the  animal  which  they 
may  nourish,  possess  the  common  property  of  being  composed  of  fat, 
proteids,  carbohydrates,  mineral  substances,  and  water  in  varying 
proportions.  The  purposes  that  these  serve  in  the  animal  economy 
are  essentially  the  same  in  all  forms  of  animal  life.  In  order  to 
determine  the  food- value  of  any  substance,  a  chemical  anahsis 
which  shows  the  quantities  of  these  nutritional  elements  is  required. 
It  will  be  found  that  foods  varying  widely  in  appearance  and  physical 
properties  are  still  similar  in  that  the}^  are  composed  of  the  same 
food  elements,  although  in  different  proportions. 

Foods  used  to  sustain  animal  life  in  any  form  must  contain  the 
ingredients  needed  by  all  animals,  and  they  must  be  present  in  a 
form  suited  to  the  particular  kind  of  animal  to  be  fed,  whether  it- is 
man  or  one  of  the  lower  animals. 

The  Ingredients  of  Foods. — All  foods  are  composed  of  fat,  carbo- 
hydrates, proteids,  mineral  substance,  and  water,  but  these  elements 
exist  in  widely  differing  formes.  Fat  may  be  supplied  in  meat, 
cream  or  milk,  butter,  oleomargerine  or  butterine,  lard,  olive  oil, 
cod-liver  oil,  linseed  oil,  cottonseed  oil.  etc.  Carbohydrates  may 
be  furnished  in  the  form  of  cane-sugar,  milk-sugar,  maltose,  and 
dextrose-soluble  products  derived  from  starch,  cornstarch,  wheat  or 
other  flour,  oatmeal,  rice,  hominy,  bread,  potatoes,  etc.  Proteids 
are  secured  in  the  form  of  lean  beef,  lamb  or  pork,  chicken,  fish,  the 
gluten  of  such  cereals  as  wheat  and  oats,  and  also  in  large  quantities 


6o  NUTRITION   AND    GROWTH 

from  peas,  beans,  lentils,  and  other  legumes,  from  the  curd  of  milk,, 
and  also  from  eggs.  The  mineral  substances  of  food  are  found 
combined  with  the  other  ingredients  in  the  form  of  lime,  phosphates, 
magnesium,  etc. 

The  Function  of  the  Food  Elements. — The  proteids  of  the  food 
are  used  to  form  the  bodily  structures  and  to  replace  tissue  consumed 
by  the  vital  processes  and  excreted  as  urea.  The  vital  processes,  such 
as  the  circulation  of  the  blood,  respiration,  and  contractions  of  the 
muscles,  call  for  energ}^,  and  this  together  with  bodily  heat  must  be 
supplied  by  the  fats  and  carbohydrates.  The  mineral  substances 
are  used  in  the  formation  of  bone  and  teeth,  while  the  water  serves 
to  dissolve  the  food  elements  after  they  have  been  digested  and  to 
carry  off  waste  products. 

The  Advantage  of  a  Knowledge  of  the  Composition  ot  Foods. — 
Inasmuch  as  each  food  element  has  a  special  function  to  perform, 
and  since  growth  is  impossible  without  a  sufhcient  supply  of  these 
nutritional  elements,  particularly  the  proteid,  it  is  essential  to  know 
within  reasonable  limits  the  composition  of  a  food,  because  if  the 
elements  are  not  present  in  proper  proportions,  disappointing  results 
may  be  obtained  from  their  use  which  will  appear  inexplicable,  but 
which  will  readily  be  accounted  for  if  we  know  what  element  of  the 
food  is  at  fault.  For  these  reasons  it  is  coming  to  be  the  practice, 
in  infant-feeding  especially,  to  speak  of  the  percentage  composition 
of  the  milk -foods,  as,  for  example,  a  food  containing  4  percent  fat, 
7  percent  carbohydrates,  2  percent  proteids,  and  35  percent  min- 
eral substances.  Knowing  from  wide  experience  the  percentages 
of  these  ingredients  generally  needed  in  a  food  if  it  is  properly  to 
nourish  a  child,  it  becomes  possible  to  know  in  an  instant  whether 
an  infant  is  having  a  food  of  suitable  nutritive  value,  by  comparing 
its  known  composition  with  that  established  by  experiment,  as 
requisite. 

The  Selection  of  Food. — In  looking  over  analyses  of  foods  many 
substances  will  be  noticed  which,  according  to  their  chemical  com- 
position, have  the  same  food-value,  but  which  common  sense  tells 
us  are  not  interchangeable.  For  instance,  no  one  would  attempt  to 
feed  cracked  oats  to  a  human  being  unless  thoroughly  cooked,  but 
he  would  give  them  raw  to  the  lower  animals.  They  will  nourish  a 
man  or  the  animal  equally  well,  but  for  man  they  must  be  prepared, 
while  the  horse,  for  example,  can  utilize  them  in  their  original  state. 
This  illustrates  the  importance  of  adapting  food  to  the  consumer. 
Often  the  question  in  feeding  is  not  so  much,  Is  the  food  nutritious? 
as,  Can  the  patient  assimilate  it?  Oftentimes  success  in  infant- 
feeding  lies  in  the  physician's  ability  to  discover  a  form  of  fat, 
carbohydrate,  and  proteid  which  the  infant  can  assimilate.  In  the 
following  pages  feeding  measures  for  temporary  use  will  be  found 
which  may  not  conform  to  what  some  may  consider  strictly  scientific 


GENERAL    PROPERTIES    OF   FOODS  6 1 

principles;  yet  they  often  give  brilliant  results.  Looking  a  little 
below  the  surface,  it  will  be  found  that  the  measures  suggested  are 
not  unscientific,  and  that  the  results  are  due  to  applying  the  fixed 
principles  of  nutrition  in  perhaps  novel  or  unusual  ways.  It  is 
usually  best  to  follow  the  most  direct  route  to  any  place,  but  when 
this  is  badly  blocked,  it  is  better  to  go  another  way,  if  there  is  one, 
rather  than  not  to  arrive  at  one's  destination. 

General  Properties  of  Milks. — \\'hen  most  young  animals  are 
born  their  digestive  organs  are  in  a  more  or  less  embrvonic  condition, 
and  it  is  several  months  before  they  entirely  outgrow  this  state. 
During  this  period  the  nourishment  is  supplied  by  the  mother 
through  her  mammary  glands,  first  as  colostrum  and  later  as  milk. 
When  these  secretions  are  analyzed  they  are  found  to  consist  of  fat, 
carbohydrates,  proteids,  mineral  substances,  and  water,  and  in  this 
respect  they  do  not  differ  from  other  foods.  But  the  elements  exist 
in  the  secretion  in  peculiar  forms,  and  the  natural  inference  is  that 
in  some  way  they  must  be  particularly  suited  to  animals  whose 
digestive  organs  are  still  undeveloped. 

The  digestive  secretions  of  the  stomachs  of  all  known  animals 
contain  pepsin  and  hydrochloric  acid.  In  the  very  young  these 
secretions  are  feeble,  but  as  development  proceeds  they  are  much 
more  abundant.  To  understand  milk  as  a  food  one  must  know  the 
effect  upon  it  of  pepsin  and  acid.  When  pepsin  is  added  to  tepid 
cow's  milk  it  causes  the  milk  to  gelatinize,  with  the  formation  of  curd 
or  junket.  If  the  milk  is  slightly  acidified  or  soured,  the  curd  formed 
is  dense  and  solid  and  more  difficult  of  digestion.  When  the  milk 
of  the  cow  or  the  ass  or  human  milk  is  treated  with  pepsin  and  acid 
in  exactly  the  same  way,  curds  totally  different  are  formed,  and  as 
the  human  digestive  organs  are  different  from  those  of  the  cow  or 
the  ass  it  is  believed  that  these  differences  in  the  digestive  properties 
of  milks  are  for  the  purposes  of  making  the  milks  suitable  for  the 
different  kinds  of  digestive  tracts.  Milks  may  be  regarded  as  special 
forms  of  food  which  require  greater  digestive  effort  as  the  digestive 
secretions  of  the  stomach  become  stronger,  and  thus  solid  food  is 
furnished  to  the  developing  stomach.  It  is  that  portion  of  the 
proteid  of  the  milk  called  "casein"  that  is  changed  into  a  solid  by 
the  pepsin  of  the  stomach.  The  term  casein,  however,  has  been 
loosely  applied  to  all  the  proteids  of  all  milks.  The  caseins  of  all 
milks  are  not  alike  in  their  digestive  properties.  Therefore  the 
mistake  of  so  considering  them  should  be  guarded  against.  A 
consideration  of  such  a  modification  and  adaptation  of  cow's  milk 
as  will  make  it  acceptable  to  the  infant's  digestive  possibilities  will 
be  found  in  the  chapters  dealing  with  Substitute  Feeding. 


62  NUTRITION    AND    GROWTH 


MATERNAL  NURSING 

Writers  on  this  subject  are  very  apt  to  state  that  the  abihty  of 
the  mother,  particularly  among  the  well-to-do,  to  fulfil  this  most 
important  function  is  surely  decreasing.  This  may  have  been  a  true 
statement  a  decade  ago ;  at  the  present  time,  however,  1  am  sure  it 
is  erroneous.  In  my  own  medical  life  I  have  seen  a  change  for  the 
better,  particularly  during  the  past  five  years.  The  young  mother 
of  today  is  better  able  to  nurse  her  offspring  than  was  her  sister  five 
or  ten  years  ago.  I  attribute  this  to  the  fact  that  the  youth  of  the 
present  day  are  more  vigorous,  more  nearly  normal  individuals  than 
were  those  of  a  decade  ago.  The  inability  to  perform  the  nursing 
function  so  that  it  will  be  successful  has  always  been  attributed  to 
the  mother  per  sc.  This,  I  think,  is  an  error.  Not  every  breast- 
milk  for  two  or  three  weeks  after  parturition  is  ideal,  as  I  have  found 
by  the  examinations  of  hundreds  of  them.  If  a  child  is  bom  with 
a  generally  enfeebled  vitality,  it  keenly  feels  any  slight  abnormality 
in  the  milk,  or  it  may  not  be  able  to  digest  perfectly  normal  milk ; 
in  either  event,  the  milk  disagrees  and  the  nursing  is  discontinued. 
Breast-milk  during  the  first  two  or  three  weeks  of  the  infant's  life 
is  produced  under  conditions  which  are  unfavorable — conditions 
which  do  not  indicate  the  possibilities  of  the  breast  as  a  secreting 
organ.  Following,  as  it  does,  upon  the  stress  of  confinement,  it  is 
not  indicative  of  what  may  be  possible  later  when  the  customary 
life  and  daily  habits  are  resumed.  Repeatedly  I  have  found  a  very 
high  fat  or  a  high  proteid,  or  both,  during  the  first  week  or  two, 
entirely  corrected  later  without  interference.  This  condition  at 
the  time  was  considered  sufficiently  serious  to  warrant  the  discon- 
tinuance of  nursing  on  the  part  of  a  weakh^  infant,  while  in  a  vigorous 
infant  it  would  be  entirely  ignored. 

The  change  which  enables  more  mothers  successfully  to  nurse 
their  infants  is  due  to  two  causes — more  vigorous  fathers  and  mothers 
and  more  vigorous  offspring.  Following  this  line  of  reasoning,  the 
more  normal  the  mother,  the  better  able  is  she  to  perform  this 
normal  function.  That  this  is  the  case  is  due,  I  beheve,  to  the  fact 
that  growing  girls  and  young  women  are  leading  more  hygienic 
lives  than  formerly.  The  making  of  golf,  bicycle  and  horseback 
riding,  boating,  and  automobiling  popular  and  fashionable — in  short, 
the  taking  of  girls  out  of  doors  and  keeping  them  there  a  consider- 
able portion  of  the  day — has  worked  a  marvelous  change  for  the 
better,  both  physically  and  mentally.  A  neurotic  mother  makes 
the  poorest  possible  milk-producer.  Proportionate  to  the  population, 
there  are  fewer  neurasthenics  among  the  young  women  today  than 
there  were  ten  years  ago,  and  there  will  be  still  fewer  ten  years  hence. 
At  the  present  time  the  timid,  retiring  young  woman  of  the  neuras- 
thenic type  is  not  popular  in  her  set.     It  is  a  fortunate  thing  for  the 


MATERNAL   NURSING  63. 

future  of  the  human  race,  at  least  for  that  portion  of  it  which  resides 
in  the  United  States,  that  the  young  woman  has  transferred  her  alle- 
giance from  the  crochet  and  embroidery  needle  to  the  golf  club.  It 
may  be  said  that  our  argument  holds  only  with  the  wealthy  or  the 
well-to-do.  Imitation  is  one  of  the  strongest  characteristics  of  the 
human  race,  and  this  tendency  in  America  to  outdoor  hygienic  living 
pervades  all  classes.  vSaturday  half-holidays,  the  excursions  and 
outings  afforded  by  reduced  rates  in  transportation,  are  much  more 
popular  than  they  were  ten  years  ago.  Food  is  better  selected  and 
better  prepared,  owing  to  increased  knowledge  on  the  part  of  the 
people  as  to  what  constitutes  proper  nutrition.  These  are  facts, 
in  spite  of  the  sensational  novelists  and  magazine-writers. 

A  feature  which  marks  an  important  advance  in  the  right  direction 
is  the  establishment  of  a  department  in  dietetics  and  food  economics 
in  the  New  York  Training  School  for  Teachers.  The  Dean,  Dr.  James 
E.  Russell,  in  establishing  this  course  is  producing  benefits  which  per- 
haps are  more  far-reaching  than  he  realizes.  The  students  are  taught 
food  values,  food  preparation,  and  food  economics,  which  consists  in 
providing  for  a  given  amount  of  money  the  most  nutritious  food  in  its 
most  attractive  form.  Hundreds  of  teachers  are  sent  out  from  this 
institution  every  year  to  take  their  places  of  usefulness  as  instructors 
of  the  young  in  all  portions  of  the  country.  Each  has  learned  some- 
thing of  food  values,  and,  better  still,  each  has  had  impressed  upon 
him  or  her  the  importance  of  the  proper  nutrition  of  a  growing 
child.  They  are  taught  that,  without  this,  the  best  possible  type 
of  adult  cannot  be  produced.  As  a  result  of  such  instruction  they 
wall  be  of  far  greater  service  in  their  fields  of  labor ;  for  not  only  can 
they  teach  what  is  laid  down  in  the  books,  but,  what  is  equally  if 
not  more  important,  they  are  competent  to  teach  those  under 
their  care  how  to  live;  and  those  who  live  properly,  grow  properly, 
following  out  the  maxim  of  Herbert  Spencer  that  "the  first  requisite 
for  success  in  life,  is  to  be  a  good  animal;  and  to  be  a  nation  of  good 
animals,  is  the  first  condition  of  national  prosperity."  It  may  be 
thought  that  we  have  wandered  far  from  our  subject — maternal 
nursing,  but  such  is  not  the  case ;  for  conditions  which  relate  to  this 
important  function,  even  remotely,  demand  our  respectful  consid- 
eration. The  food  and  care  of  the  growing  girl  have  the  most  intimate 
bearing  upon  her  future  life,  and  if  she  is  to  be  called  upon  to  per- 
form the  most  important  function  of  womanhood,  she  surely  has  the 
right  to  demand  that  she  receive  during  her  girlhood  proper  prepara- 
tion, which  heretofore  has  too  often  been  denied  her. 

It  is  not  pleasant  to  criticize  physicians ;  but  friendly  criticism 
should  always  be  welcomed.  The  family  physician  does  not,  in  a 
great  majority  of  instances,  fulfil  his  function,  or  extend  his  field  of 
usefulness  to  its  full  capacity,  his  conception  of  duty  too  often  in- 
cluding only  the  sick.     Unsought  advice  as  to  the  feeding  and  daily 


64  NUTRITION    AND    GROWTH 

habits  of  a  child's  hfe,  I  find  are  usually  welcomed  and  appreciated  by 
the  parents.  In  practically  every  instance,  according  to  my  obser- 
vation, errors  in  a  child's  management  are  due  to  ignorance.  Parents, 
no  matter  what  their  station  in  life,  are  glad  to  do  what  is  for  the  best 
interests  of  their  children  when  it  is  made  clear  to  them.  It  is  our 
duty  to  take  parents  into  our  confidence  and  explain  to  them  the 
reasons  for  the  line  of  action  advised.  When  they  appreciate  the 
reason  for  certain  procedures,  I  find  that  they  are  far  more  apt  to 
follow  them.  I  am  confident  from  observations  upon  many  cases 
that  if  I  could  have  the  physical  direction  of  ten  average  girls  in  any 
station  in  life,  provided  that  they  could  have  the  benefit  of  fresh 
air  and  good  food  from  infancy  to  adolescence,  successful  nursing 
mothers  could  be  made  out  of  eight  of  them.  Certain  rules  of 
life  having  a  direct  bearing  on  nursing  lead  us  nearer  the  ideal  and 
may  enable  one  who  otherwise  could  not  nurse  her  child  to  do  so 
successfully.  These  requirements,  it  will  be  seen,  are  laid  along 
common-sense  lines  and  cause  no  hardship  or  mental  distress — one 
of  the  chief  requirements  of  a  nursing  woman  being  that  she  shall 
be  mentally  normal. 

There  are  few  conditions  in  which  we  are  called  to  act  so  variable 
and  so  uncertain  as  is  the  production  of  breast-milk.  Breast-milk 
is  one  of  the  most  precious  substances.  It  is  invaluable  unless  we 
can  put  a  value  on  human  life.  The  most  successful  nursing  age  is 
between  the  twentieth  and  thirty-fifth  years.  I  have,  however, 
seen  it  successfully  carried  on  in  a  girl  of  fourteen,  in  a  woman  of 
fifty- two,  and  in  the  much  abused  society  girl,  while  I  have  seen 
it  fail  absolutely  in  peasant  women  fresh  from  the  fields  of  Hungary 
and  Bohemia.  I  have  seen  those  in  whom  at  first  the  nursing  was 
most  unsatisfactory,  develop  into  perfect  nurses. 

Some  mothers  will  be  able  to  carry  on  the  nursing  for  only  two 
months ;  others,  three,  five,  seven,  or  nine  months.  In  my  experience 
whether  in  out-patient  or  in  private  practice,  it  is  extremely  rare 
for  the  breast-milk  to  be  sufficient  for  a  child  after  the  ninth 
month. 

The  following  can  be  laid  down  as  nursing  axioms : 

A  diet  similar  to  what  the  mother  was  accustomed  to  before  the 
advent  of  motherhood  should  be  taken. 

There  should  be  one  bowel  evacuation  daily. 

There  should  be  from  three  to  four  hours  daily  spent  in  the  open 
air  with  exercise  which  does  not  fatigue. 

There  should  be  at  least  eight  hours'  sleep  out  of  every  twenty- 
four. 

There  should  be  absolute  regularity  in  nursing. 

There  should  be  no  worry  and  no  excitement. 

The  mother  should  be  temperate  in  all  things. 

The  Diet. — I  have  many  times  been  consulted  by  nursing  mothers 


MATERNAL    NURSING  65 

because  the  nursing  was  unsuccessful  or  a  partial  failure,  and  have 
found  that  their  diet  has  been  restricted  to  an  extreme  degree. 
To  put  on  a  greatly  restricted  diet  a  robust  young  mother  who  has 
always  eaten  bountifully  of  a  generous  variety  of  foods  is  one  of  the 
best  means  of  curtailing  the  quantity  and  lowering  the  quality  of 
her  milk-supply.  \A'hen  asked  to  prescribe  a  diet  I  tell  them  to  eat 
practically  as  they  were  accustomed  to  before  the  advent  of  preg- 
nancy and  motherhood.  That  this  particular  vegetable  or  that  par- 
ticular fruit  should  be  forbidden  on  general  principles  is  a  fallacy. 
Food  that  the  patient  can  digest  without  inconvenience  is  a  safe 
food  so  far  as  the  nursing  is  concerned,  as  may  readily  be  determined 
in  any  given  case.  If  a  wide  range  of  diet  is  prescribed  in  some 
individuals,  a  plain,  more  or  less  restricted  diet  is  desirable  in  others. 
This  must  be  remembered  in  the  management  of  the  wet-nurse 
(page  74).  Many  a  wet-nurse  who  has  been  carefully  selected, 
who  to  the  best  of  our  judgment  should  prove  satisfactorv,  utterly 
fails  in  a  few  days  to  fulfil  the  duties  of  the  office  for  which  she  was 
chosen.  In  not  a  few  instances  the  failure  is  due  to  a  very  full  diet 
of  unusual  articles  of  food,  the  existence  of  which,  in  many  instances, 
she  never  dreamed  of.  Indigestion  and  constipation  follow,  and 
both  the  nurse  and  the  baby  are  made  ill  and  the  woman's  usefulness 
ceases.  A  woman  who  has  lived  and  kept  well  on  the  diet  and  food 
found  in  the  home  of  the  laboring-man,  whether  in  the  city  or  country, 
will  make  a  far  better  wet-nurse  on  this  diet  than  if  she  indulges  in 
food  to  which  she  is  entirely  unaccustomed.  The  diet  of  a  nursing 
mother,  then,  should  in  general  be  as  above  stated. 

Nursing  is  a  perfectly  normal  function,  and  a  woman  should 
be  permitted  to  carry  it  out  along  only  natural  lines.  Inasmuch  as 
there  are  two  lives  to  be  provided  for  instead  of  one,  more  food, 
particularly  of  a  liquid  character,  may  be  taken  than  she  may  have 
been  accustumed  to.  It  is  my  custom  to  advise  that  milk  be  given 
freely.  A  glass  of  milk  may  be  taken  in  the  middle  of  the  afternoon 
and  eight  ounces  of  milk  with  eight  ounces  of  oatmeal  or  cornmeal 
gruel  at  bedtime,  if  it  does  not  disagree  with  the  patient.  Our  only 
evidence  that  a  food  is  not  disagreeing  is  the  condition  of  the  digestion. 
When  any  article  of  food  disagrees  with  the  mother,  or  if  she  is 
convinced  that  it  disagrees,  whether  or  not  such  is  really  the  case, 
the  food  should  be  discontinued.  In  a  general  way,  milk  in  quan- 
tities not  over  one  quart  daily,  eggs,  meat,  fish,  poultry,  cereals, 
green  vegetables,  and  stewed  fruit  constitute  a  basis  for  selection. 
The  method  of  preparation  for  the  different  meals  is  not  arbitrary. 

The  Bowel  Function. — A  very  important  and  often  neglected 
matter  in  relation  to  nursing  is  the  condition  of  the  bowels.  There 
must  be  one  free  evacuation  daily.  For  the  treatment  of  constipa- 
tion in  nursing  women  I  have  used  different  methods  in  many  cases. 
The  dietetic  treatment  does  not  promise  much.  For  here,  again, 
5 


66  NUTRITION    AND    GROWTH 

manipulation  of  the  diet  may  interfere  with  the  milk  production. 
Three  methods  are  open  to  use — massage,  local  measures,  and  drugs. 
Massage  is  available  in  comparatively  few  cases.  Local  measures 
consist  in  the  use  of  enemas  or  suppositories.  Every  nursing  woman 
under  my  care  is  instructed  to  use  an  enema  at  bedtime  if  no  evacua- 
tion of  the  bowels  has  taken  place  during  the  previous  twenty-four 
hours.  Many  out-patients,  in  whom  constipation  is  very  prevalent, 
indulge  in  excessive  tea-drinking,  taking  often  from  one  to  two 
gallons  of  tea  daily.  In  such  patients  where  an  absolute  discon- 
tinuance of  the  tea-drinking  is  often  impossible  and  not  absolutely 
necessary,  I  usually  allow  two  cups  a  day.  For  a  laxative  in  such 
cases  and  in  many  others,  a  capsule  of  the  following  composition 
has  served  me  well: 

I^.     Extract!  belladonna? gr.  ^ 

Extract!  nucis  vomicae gr.  i 

Extract!  cascara;  sagrads gr.  v 

M.  et  ft.  capsula  No.  j. 

Slg. — To  be  taken  at  bedtime. 

The  amount  of  the  cascara  sagrada  may  be  varied  as  the  case  may 
require.  In  not  a  few  instances  I  have  found  it  necessary  to  give 
two  capsules  a  day  in  order  to  produce  the  desired  result.  Neither 
the  belladonna,  the  nux  vomica,  nor  the  cascara  appears  to  have 
any  appreciable  effect  on  the  child. 

Air  and  Exercise. — Outdoor  life  and  exercise  are  desirable  here 
as  they  are  under  all  other  conditions.  In  a  nursing  woman  with 
her  added  responsibility,  they  are  doubly  so.  In  order  to  get  the 
best  results,  exercise  or  work  should  so  be  adjusted  as  not  to  reach 
the  point  of  fatigue.  The  mother  whose  nights  are  disturbed  should 
be  given  the  benefit  of  a  midday  rest  of  an  hour  or  two.  She 
should  have  at  least  eight  hours'  sleep  out  of  every  twenty-four. 
Certain  annoyances,  anxieties,  and  worries  are  inseparable  from  the 
life  of  every  child-bearing  woman.  It  should  be  our  duty,  however, 
to  explain  to  the  mother  and  to  other  members  of  the  family  that  an 
important  element  in  satisfactory  nursing  is  a  tranquil  mind.  Dur- 
ing the  lactation  period  she  should  be  spared  all  tmnecessary  care 
and  petty  annoyances. 

Regularity  in  Nursing. — The  breast  which  is  emptied  at  definite 
intervals  invariably  works  better  than  does  one  which  is  not,  not 
only  as  regards  the  quantity,  but  the  quality  of  the  milk  as  well; 
so  that  system  in  breast-feeding  is  almost  as  essential  to  milk- 
production  as  to  its  digestion  and  assimilation. 

After  it  is  demonstrated  that  the  nursing  is  progressing  satis- 
factorily as  proved  by  the  satisfied,  thriving  child,  I  begin  with  one 
bottle-feeding  daily.  The  advisability  is  obvious;  in  case  of  illness 
of  the  mother,  if  she  is  called  away  from  home,  or  if,  for  any  reason, 
the  child  cannot  have  the  breast,  the  feeding  is  provided  for.     An- 


MATlvRNAL    NURSING  67 

other  advantage  is  that  it  gives  the  mother  needed  freedom  from 
restraint.  She  is  thus  enabled  to  have  the  benefit  of  a  change  of 
scene.  Amusements  and  recreations  which  the  invariable  nursing 
period  denies  her  can  be  indulged  in.  As  a  result  of  this  greater 
freedom,  she  is  able  to  supply  better  milk  and  to  continue  nursing 
longer  than  if  tied  continually  to  the  baby,  no  matter  how  fond  she 
may  be  of  it. 

Signs  of  Successful  Nursing. — The  child  shows  a  gain  of  not  less 
than  four  ounces  weekly.  This  is  the  minimum  weekly  gain  which 
may  safely  be  allowed.  When  a  nursing  baby  remains  stationary  in 
weight  or  makes  a  gain  of  but  two  or  three  ounces  a  week,  it  means 
that  something  is  wrong,  and  it  will  usually,  but  not  invariably,  be 
found  in  the  milk-supply.  When  the  baby  is  nursed  at  proper 
intervals  and  the  supply  of  milk  is  ample  and  of  good  quality,  he  is 
satisfied  at  the  completion  of  the  nursing.  If  he  is  under  three 
months  of  age,  he  falls  asleep  after  ten  or  twenty  minutes  at  the 
breast.  Wlien  the  nursing  period  again  approaches,  he  becomes 
restless  and  unhappy,  crying  lustily  if  the  nursing  is  delayed.  When 
the  breast  is  offered,  he  takes  it  greedily.  The  stools  are  yellow 
and  number  from  two  to  three  daily.  The  weekly  gain  in  weight 
under  such  conditions  is  usually  from  six  to  eight  ounces. 

Signs  of  Unsuccessful  Nursing. — Theoretically,  every  normal 
breast  baby  should  be  a  thriving,  well  baby.  That  such  is  not  the 
case,  is  an  unfortunate  fact.  The  standard  established  for  a  well 
baby  is  not  upheld  here.  When  the  supply  of  milk  is  scanty  the 
child  remains  long  at  the  breast  and  cries  when  he  is  removed.  He 
shows  signs  of  hunger  before  the  nursing  hour  arrives.  A  cause  of 
failure  in  breast-feeding,  and  probably  the  most  frequent  cause,  is 
a  scanty  milk-supply.  The  chief  nutritional  elements  in  mother's 
milk  are  fat,  3  to  4  percent;  sugar,  7  percent;  proteid,  1.5  percent. 
Failure  may  be  due  to  a  marked  disproportion  of  these  elements 
which  may  cause  sufficient  indigestion  and  resulting  loss  in  weight 
to  necessitate  a  discontinuance  of  nursing.  Thus  there  may  be  a 
high  fat — from  5  to  6  percent;  or  very  low  fat — from  i  to  1.5  per- 
cent. In  the  high-fat  cases  there  will  usually  be  diarrhea  with  green, 
watery  stools.  The  child  strains  a  great  deal  and  there  are  green 
stains  on  many  of  the  napkins.  In  high-fat  cases  there  is  also  regur- 
gitation or  vomiting  of  sour  material.  The  fat-globules  may  readily 
be  made  out  if  the  vomited  material  is  placed  under  a  low-power 
microscope.  Low  fat  means  deficient  nourishment  and  may  cause 
constipation.  Sugar  is  rarely  a  cause  of  trouble  in  nursing  babies. 
It  seldom  varies,  ranging  from  5  to  7  percent  in  the  great  majority 
of  breast-milks.  Young  children,  further,  have  a  marked  toleration 
for  it.  The  proteid  of  mother's  milk  is  the  most  frequent  cause  of 
nursing  difficulties.  Like  the  fat,  it  may  so  be  decreased  that 
nutritional  disorder  may  be  induced  in  the  patient,  or  it  may  be 


68  NUTRITION    AND    GROWTH 

very  much  increased,  the  latter  being  usually  the  cause  of  colic  or 
constipation  in  otherwise  healthy  nursing  infants.  In  such  infants 
curds  may  be  found  in  the  stools,  the  passage  of  which  is  always 
accompanied  by  a  great  deal  of  gas.  The  milk  may  contain  the 
normal  percentage  of  fat,  sugar,  and  proteid,  but  be  scanty  in 
amount.  Instead  of  the  four  or  five  ounces  to  which  the  child  is 
entitled,  he  may  get  but  one  or  two  ounces.  Whether  or  not  the 
quantity  is  sufhcient,  can  be  determined  by  weighing  the  baby 
before  and  after  each  nursing  for  twenty-four  hours.  One  ounce  of 
breast-milk  weighs  practically  one  ounce  avoirdupois.  The  quality 
or  strength  is  determined  by  an  examination  of  the  milk  itself 
(page  76).  Before  nursing,  the  child  is  put  in  the  scales  without 
undressing  him  and  the  weight  noted.  He  is  allowed  to  nurse 
fifteen  minutes.  He  is  then  removed  from  the  breast  and  weighed. 
A  child  under  one  week  old  should  gain  from  i  to  i^  ounces;  at 
three  weeks  of  age,  i^  to  2  ounces;  four  to  eight  weeks  of  age,  2  to 
3  ounces;  eight  to  sixteen  weeks  of  age,  3  to  4  ounces;  sixteen  to 
twenty-four  weeks  of  age,  4  to  6  ounces;  six  to  nine  months  of  age, 
6  to  8  ounces ;  nine  to  twelve  months  of  age,  8  to  9  ounces.  Of 
course,  arbitrary  limits  cannot  be  fixed  as  to  the  quantity. 

Stationary  weight  or  loss  in  weight  with  a  dissatisfied  child  usually 
means  defects  in  quantity  which  are  readily  proved  by  the  weighing. 
To  be  fed  at  the  breast  may  also  cause  the  child  to  suffer  from  an 
excess  of  good  milk,  in  which  event  there  will  be  vomiting  or  regurgi- 
tation, usually  associated  with  colic.  When  this  overfeeding  con- 
tinues, dilatation  of  the  stomach  develops,  vomiting  becomes 
habitual,  the  child  loses  in  weight,  and  the  breast-milk  is  said  not 
to  agree,  and  often,  unfortunately,  the  baby  is  weaned.  This  has 
been  the  outcome  in  scores  of  cases.  When  there  is  habitual  vomit- 
ing and  colic  in  a  nursing  baby,  two  things  are  to  be  done — the 
baby  must  be  weighed  before  and  after  nursing,  and  the  milk  must 
be  examined. 

I  have  repeatedly  treated  children  for  indigestion  who  were 
entirely  relieved  by  shortening  the  nursing  period.  Weighing  the 
baby  at  intervals  of  from  three  to  five  minutes  and  noting  the  gain 
has  shown  that  the  three  or  four  ounces  which  may  be  the  child's 
stomach  capacity  were  obtained  in  two,  three,  or  five  minutes,  the 
excess  which  the  child  took  over  this  amount  being  the  cause  of  his 
trouble.  Given  a  free,  full  breast  and  a  vigorous  nurser,  and  one 
ounce  will  be  taken  in  one  minute.  When  the  nursing  "gait"  is 
established,  a  child  should  be  kept  up  to  the  schedule.  There  are 
few  more  pernicious  teachings  than  that  a  baby  should  be  allowed 
to  nurse  when  he  wants  to  and  as  long  as  he  wants  to.  The  idea 
that  a  nursing  infant  will  take  no  more  than  is  good  for  him  is  the 
fruit  of  inexperience.  Recently  a  mother  consulted  me  in  regard  to 
putting  her  one-month-old  baby  on  the  bottle,  as  he  had  many  green 


MATERNAT.    NURSING  69 

stools,  cried  a  great  part  of  his  waking  hours,  and  weighed  but  a  few 
ounces  more  than  at  birth.  Her  milk  was  supposed  to  be  "too 
strong"  for  the  child.  An  examination  of  the  breast  and  a  talk  with 
the  mother  satisfied  me  that  the  breast-milk  was  not  at  fault.  An 
examination  of  the  milk  proved  it  to  be  good  average  milk — 3.5 
percent  fat,  6  percent  sugar,  1.45  percent  proteid.  A  one  day's 
test  by  weighing  was  decided  upon.  He  was  allowed  to  nurse  one 
minute  and  rest  one  minute.  During  the  resting  period  he  was 
weighed.  Weighing  and  resting  him  in  this  way,  it  was  found  that 
in  three  minutes  he  got  from  3  to  3^  ounces  of  milk.  The  nursing 
was  then  reduced  to  three  minutes  on  one  breast  and  five  minutes 
on  the  other,  which  was  the  "slower"  breast  of  the  two.  Every 
sign  of  indigestion  promptly  disappeared  after  this  change.  The 
stools  became  normal  and  the  infant  made  a  satisfactory  gain  in 
weight  of  one  ounce  daily. 

The  quantity  may  be  suitable  for  the  age  of  the  child,  he  may 
not  vomit  or  show  a  sign  of  indigestion,  and  yet  he  may  not  thrive. 
In  such  a  case  an  examination  or  repeated  examinations  of  the  milk 
at  intervals  of  two  or  three  days  will  usually  show  that  it  is  poor, 
below  the  normal  perhaps  in  both  fat  and  proteid.  Such  a  case 
occurred  in  the  New  York  Infant  Asylum.  A  Swedish  woman  was 
admitted  with  an  infant  two  months  old  in  fair  condition.  She  had 
an  abundance  of  milk  and  asked  for  a  foster-child,  so  great  was  her 
discomfort  from  the  excessive  flow  of  milk.  The  weekly  weighings 
of  the  children  soon  revealed  that  there  was  no  growth,  and  after 
a  few  weeks  both  children  upon  examination  showed  developing 
rickets.  The  milk  was  then  examined  and  was  found  deficient — ■ 
fat  1.2  percent,  sugar  5  percent,  and  proteid  0.73  percent. 

Signs  of  Insufficient  Nursing. — The  baby  remains  long  at  the 
breast,  perhaps  one-half  to  three-quarters  of  an  hour.  When  re- 
moved, he  is  restless  and  uncomfortable.  After  a  short  time,  in  an 
hour  or  less,  he  is  very  hungry  and  demands  frequent  nursings  day 
and  night. 

Management  of  Abnormal  Milk  Conditions. — When  it  is  found 
that  the  breast-milk  is  too  strong  or  too  weak,  or  when  the  normal 
ratios  of  fat,  sugar,  and  proteid  are  not  maintained,  it  may  be 
possible  to  increase  or  diminish  the  milk  strength.  It  may.  also  be 
possible  to  increase  either  the  fat  or  the  proteid  when  desirable. 
The  heavy  milk  will  usually  be  found  in  mothers  who  are  robust, 
who  eat  heartily,  and  who  take  but  little  exercise.  In  such  a  mother, 
the  prescribing  of  a  plain  diet,  allowing  red  meat  but  once  a  day, 
discontinuing  the  malt  liquors  or  wine, — which  it  will  often  be  found 
that  she  is  taking, — and  directing  that  she  walk  a  mile  or  two  a  day, 
will  frequently  bring  the  milk  to  digestible  proportions.  In  some 
cases,  however,  this  will  not  be  successful,  and  the  colic,  constipation, 
and  vomiting  continue,  even  though  the  quantity  obtained  at  each 


70  NUTRITION    AND    GROWTH 

nursing  is  within  normal  limits.  In  some  mothers  it  will  be  impos- 
sible to  change  the  mode  of  life,  except  perhaps  as  to  the  discon- 
tinuance of  alcohol.  When  such  conditions  prevail,  the  mother's 
milk  may  be  modified  by  giving  from  one-half  to  one  ounce  of  boiled 
water  or  plain  barley-water  before  each  nursing.  This  is  a  procedure 
to  which  I  frequently  resort.  One  teaspoonful  of  lime-water  added 
to  one  ounce  of  water  before  each  nursing  has  made  the  breast-milk 
agree  when  otherwise  it  would  have  been  impossible.  When  the 
milk  is  deficient  both  in  fat  and  proteid,  a  diet  composed  largely 
of  red  meat,  poultry,  fish,  rye  bread,  or  whole-wheat  bread,  oatmeal, 
cornmeal,  with  two  or  three  pints  of  milk  daily,  will  often  be  followed 
by  an  increase  both  in  fat  and  proteid.  The  use  of  alcohol  in  moder- 
ate amounts,  in  the  form  of  malt  liquors  or  wine,  will  usually  increase 
the  fat.  I  have  frequently  seen  it  advance  2  percent  in  from  two 
to  three  days.  Disappointments  in  improving  the  quantity  or 
quality  of  the  breast-milk,  however,  are  frequent. 

In  addition  to  the  one  bottle  which,  for  reasons  above  mentioned, 
is  given  early  in  the  child's  life,  I  find  it  necessary  at  the  seventh 
month  to  add  an  extra  bottle  or  two.  Usually  at  this  time  the  proteid 
in  human  milk  begins  to  diminish  in  quantity,  and  as  this  is  the 
most  important  nutritional  element,  an  insufficient  quantity  at  this 
rapidly  growing  period  of  life  is  a  matter  of  no  little  importance. 
At  the  twelfth  month,  with  very  few  exceptions,  my  nursing  babies 
are  weaned  from  necessity.  At  this  age  exclusive  nursings,  if  one 
considers  the  best  interests  of  the  child,  are  practically  out  of  the 
question.  Out  of  many  thousands  of  mothers  I  recall  but  one 
instance  where  a  mother  was  able  successfully  to  nurse  her  child 
after  the  twelfth  month.  This  remarkable  woman,  a  mother  of 
six  children,  had  nursed  every  one  of  them  exclusively  up  to  the 
fifteenth  or  the  eighteenth  month. 

Mixed  Feeding. — With  a  diminution  in  the  amount  of  milk 
secreted,  the  breast-milk  must,  of  course,  be  supplemented  by 
modified  cow's  milk.  This  method  of  feeding  is  usually  successful. 
If  the  mother  of  a  six-months-old  baby  can  satisfactorily  nurse  him 
three  times  in  twenty-four  hours,  he  is  given,  in  addition,  three 
bottle-feedings,  in  this  way  supplementing  the  mother's  milk.  It 
is  best  when  using  mixed  feedings  to  alternate  the  breast  and  the 
bottle.  The  modified  milk  strength  should  be  that  which  is  suitable 
for  the  average  child  of  his  age.  (See  Infant-Feeding,  page  81.) 
In  beginning  the  use  of  cow's  milk,  however,  it  must  be  remembered 
that  at  first  a  weaker  strength  must  be  used  than  the  child  will  re- 
quire for  growth,  this  weaker  food  being  necessary  in  order  gradu- 
ally to  accustom  him  to  the  change.  If  too  strong  a  cow's-milk 
mixture  is  given  at  first,  it  will  be  very  apt  to  disagree,  causing 
colic  and  vomiting.  Later,  when  the  child  has  become  accustomed 
to  the  new  food,  a  stronger  mixture  may  be  given.     When  a  mother 


MATERNAL    NURSING 


71 


cannot  give  her  infant  at  least  two  satisfactory  breast-feedings  daily, 
it  is  better  to  wean  the  child. 

Maternal  Conditions  under  Which  Nursing  is  Forbidden. — When 
the  mother  has  tuberculosis  in  any  of  its  various  forms  or  manifesta- 
tions, whether  it  involves  the  glands,  the  joints,  or  the  lungs,  breast- 
feeding is  to  be  forbidden.  In  epilepsy  and  syphilis  nursing  is 
likewise  forbidden.  In  nephritis  and  malignant  disease  of  any 
nature,  and  in  chorea,  nursing  should  be  discontinued.  Women 
who  are  rapidly  losing  weight  should  not  be  allowed  to  continue 
nursing  their  infants.  In  case  of  serious  illness  of  any  nature,  such 
as  typhoid  fever,  pneumonia,  or  diphtheria,  and  upon  the  advent 
of  pregnancy,  nursing  should  be  stopped. 

Care  of  the  Breasts  during  Weaning. — When  the  breast-feeding 
is  carried  on  the  usual  length  of  time, — from  nine  to  twelve  months, — 
the  process  of  weaning  ordinarily  causes  little  or  no  discomfort.  All 
that  is  usually  required  is  to  press  out  enough  of  the  milk  to  relieve 
the  patient  as  often  as  the  breast  becomes  painful,  which  may  not 
be  more  than  two  or  three  times  a  day.  When  the  weaning  is 
necessarily  abrupt,  no  little  discomfort  may  result.  If  there  is  a 
free  flow  of  milk,  which  is  apt  to  be  the  case  when  the  weaning  must 
take  place  in  the  early  nursing  period,  tightly  bandaging  the  breasts 
is  required.  When  localized  hardened  areas  occur  in  the  glands, 
they  should  be  massaged  until  softened,  and  the  bandage  reapplied 
and  worn  until  the  secretion  ceases.  When  the  weaning  can  more 
gradually  be  done,  the  best  way  is  to  give  one  less  nursing  every 
second  or  third  day  until  only  two  are  given.  After  this  has  been 
practised  for  one  week,  these  also  can  be  discontinued.  In  cases 
where  sudden  weaning  is  required,  a  saline  laxative,  such  as  citrate 
of  magnesia  or  Rochelle  salts,  should  be  given  every  day  for  five 
days — sufficient  to  produce  two  or  three  watery  evacuations  daily. 
In  the  mean  time  the  mother  should  abstain  from  fluids  of  all  kinds 
up  to  the  point  of  positive  discomfort. 

Conditions  Which  may  Temporarily  Produce  an  Unfavorable 
Effect  upon  the  Breast-milk,  but  not  Necessitate  the  Discontinuance 
of  Nursing. — The  advent  of  the  first  menstruation  period  particularly, 
and  in  some  cases  of  every  menstruation  period,  is  attended  with  an 
attack  of  colic  or  indigestion  on  the  part  of  the  child,  rarely  sufficient, 
however,  to  necessitate  the  discontinuance  of  the  nursing  even  for 
a  single  day. 

Factors  influencing  the  mental  conditions  of  the  mother,  such 
as  anger,  fright,  worry,  shock,  distress,  sorrow,  or  the  witnessing  of 
an  accident,  may  affect  the  milk  secretion  sufficiently  to  cause  no 
little  discomfort  to  the  child,  and  oftentimes  the  temporary  lessening 
of  the  flow  for  a  day  or  two.  The  influence  of  the  mental  state  upon 
the  character  of  the  milk  was  early  brought  to  my  attention  while 
resident  physician  at  the  Country  Branch  of  the  New  York  Infant 


72 


NUTRITION    AND    GROWTH 


Asylum.  In  this  institution  there  were  usually  about  two  hundred 
nursing  mothers,  the  majority  of  them  from  the  lower  walks  of  life, 
at  least  95  percent  of  the  infants  being  illegitimate.  The  necessity 
of  placing  a  considerable  number  of  these  mothers  in  wards,  and 
their  living  thus  in  close  contact,  gave  rise  to  rather  frequent  disputes, 
and  not  infrequently  to  fistic  encounters  of  a  decidedly  vigorous 
character.  After  a  particularly  active  disturbance,  several  nursing 
infants  in  the  ward  would  be  taken  suddenly  ill,  usually  with  vomit- 
ing, diarrhea,  and  fever.  When  two  or  more  infants  were  thus 
discovered  ill,  we  soon  learned  to  know  the  cause  when  inquiry  or 
evidence  furnished  by  hasty  inspection  of  the  mother  showed  that 
she  had  been  particularly  active  in  the  affair.  A  small  proportion 
of  the  mothers  were  from  the  better  walks  of  life.  Letters  of  for- 
giveness or  reproach  or  visits 
of  a  like  nature  from  fathers, 
mothers,  or  sisters,  have 
brought  many  a  sick  baby 
to  my  attention  and  caused 
me  many  anxious  moments. 
Conditions  Which  call  for 
Temporary  Discontinuance 
of  Nursing. — During  an  acute 
illness  with  fever,  such  as 
indigestion,  tonsillitis,  and 
minor  illnesses  of  a  like  na- 
ture, nursing  should  be  dis- 
continued for  a  day  or  two. 
When  the  infant  is  removed 
from  the  breast,  it  should  be 
our  effort  to  maintain  the 
flow  of  the  milk.  This  is 
best  done  by  emptying  the 
breast  with  a  breast-pump  (page  79)  at  the  usual  nursing  period 
until  the  time  arrives  when  the  nursing  may  be  resumed.  In  such 
conditions  the  advantage  of  having  the  baby  accustomed  to  one 
bottle  a  day  will  at  once  be  appreciated. 

Care  of  the  Nipples. — Six  hours  after  delivery  or  confinement 
the  nipples  should  be  washed  with  a  saturated  solution  of  boric  acid 
and  the  child  put  to  the  breast  and  nursing  attempted.  After  this, 
the  attempts  at  nursing  should  be  repeated  every  four  hours,  although 
the  milk  does  not  appear  in  the  breasts  until  from  forty-eight  to 
seventy-two  hours  after  the  birth  of  the  child.  Colostrum  may  be 
present,  which  is  useful  as  a  laxative  and  may  satisfy  the  child.  A 
further  advantage  of  the  nursing  at  this  time  is  that  it  gradually 
accustoms  both  the  nipple  and  the  infant  to  what  will  be  required 
of  them  later.     Immediately  after  the  nursing,  the  nipple  should 


Fig.  7.— Nipple-shield. 


THE   WET-NURSE  73 

be  carefully  washed  with  a  saturated  solution  of  boric  acid  and 
thoroughly  but  gently  dried.  A  baby  should  never  be  allowed  to 
nurse  on  a  cracked  or  fissured  nipple.  For  this  very  painful  con- 
dition a  nipple-shield   (Fig.  7)  should  always  be  used. 

Giving  of  Water. — From  one-half  to  one  ounce  of  a  i  percent 
solution  of  milk-sugar  should  be  given  the  infant  every  two  hours 
until  the  milk  appears  in  the  breast.  Otherwise  there  will  be  unnec- 
essary loss  in  weight  and  perhaps  a  high  degree  of  fever  due  to 
inanition. 

If  the  child  is  restless  and  uncomfortable,  it  is  safe  to  conclude 
that  he  is  thirsty,  and  one  ounce  of  the  sugar-water  will  usually 
satisfy  him.  With  the  commencement  of  nursing,  accustom  the 
babv  to  getting  his  food  at  regular  intervals. 

Frequency  of  Nursings. — The  new-born  infant  is  entitled  to 
ten  nursings  in  twenty-four  hours.  From  6  a.  m.  to  10  p.  m., 
inclusive,  there  should  be  nine  nursings.  There  may  be  one  nursing 
at  2  or  3  A.  M.  As  the  child  becomes  older  less  frequent  nursings 
are  required.  The  following  table  will  be  found  useful  in  this 
connection : 

3d    to  the  21st  day 10     nursings. 

3d     "     "       6th  week 9 

6th   "     "     12th  week 8 

3d     "     "       5th  month 7  " 

5th   "     "       7th  month 6-7 

7th"     "     12th  month 5-6 

THE  WET-NURSE 

We  are  called  upon  to  select  a  wet-nurse  under  various  conditions. 
In  a  few  families,  particularly  in  those  who  have  had  disastrous 
feeding  experiences,  we  are  asked  that  no  attempts  at  artificial 
feeding  be  made,  but  that  a  wet-nurse  be  engaged  in  advance  of  the 
confinement  so  as  to  be  ready  when  the  time  for  her  serv'ice  arrives. 
Usually,  however,  our  minds  and  those  of  the  parents  turn  to  the 
wet-nurse  when  nutrition  by  other  methods  is  a  failure.  It  is  well 
to  remember  in  this  connection  that  it  is  not  wise  to  postpone  our 
resort  to  the  wet-nurse  too  long — until  every  chance  for  her  being 
of  assistance  has  passed.  It  may  take  a  few  days'  observation  or 
but  a  single  glance  at  one  of  these  difficult  feeding  cases  for  us  to 
decide  whether  a  wet-nurse  must  be  secured.  Certain  it  is  that  in  a 
few  cases  we  cannot  do  without  them.  I  see  perhaps  two  or  three 
cases  a  year,  usually  in  consultation,  in  w^hich  I  insist  that  further 
attempts  at  artificial  feeding  be  discontinued  because  of  the  reduced 
condition  of  the  patient. 

In  the  selection  of  a  wet-nurse  the  age  during  which  nursing  is 
most  successfully  carried  on  is  to  be- remembered.  Other  things 
being  equal,  a  wet-nurse  should  not  be  under  twenty-two  or  over 
thirty-five  years  of  age.     The  peasant  women  of  the  continent  of 


74  NUTRITION    AND    GROWTH 

Europe  make  the  best  wet-nurses.  A  woman  should  not  be  selected 
as  a  wet-nurse  without  a  thorough  examination  both  of  herself  and 
of  her  infant.  She  must  be  free  from  skin  diseases,  tuberculosis, 
and  syphilis.  Whether  she  is  stout  or  thin,  tall  or  short,  amounts  to 
little.  Neither  can  we  place  much  reliance  on  the  size  of  her  breasts. 
Although  full,  firm  breasts  and  prominent  nipples  are  desirable,  the 
best  indication  as  to  her  nursing  ability  is  the  condition  of  her  baby. 
For  this  reason  it  is  best  not  to  select  a  woman  before  her  baby  is 
four  weeks  old,  for  by  that  time  his  physical  condition  will  indicate 
with  considerable  accuracy  the  kind  of  food  he  has  been  getting. 
The  age  of  the  wet-nurse's  milk  need  not  correspond  with  the  age  of 
the  patient  for  whom  she  is  engaged.  As  far  as  age  is  concerned,  a 
breast-milk  from  four  weeks  to  three  months  old  will  answer  for  any 
infant. 

The  results  attending  the  first  few  days  of  wet-nursing  are  often 
most  disappointing.  The  radical  change  which  takes  place  in  the 
nurse's  habits  of  life,  the  leaving  of  her  own  child  to  the  care  of 
others  sometimes  produces  nervous  conditions  which  may  have  a 
decidedly  unfavorable  influence  upon  her  milk.  So  before  arriving 
at  the  conclusion  that  she  will  not  answer  in  a  given  case,  she  should 
have  time  to  adjust  herself  to  the  changed  conditions.  Many  a  good 
wet-nurse  has  been  ruined,  so  far  as  her  usefulness  as  a  milk-producer 
is  concerned,  by  over-indulgence  at  the  table.  She  has  been  accus- 
tomed to  a  very  plain  diet  and  some  work,  which  necessarily  means 
exercise.  Upon  assuming  her  new  office  she  is  temporarily  the 
most  important  member  of  the  household,  next  to  the  baby,  and 
articles  of  food  are  supplied  to  which  she  is  entirely  unaccustomed 
and  of  which  she  eats  plentifully.  The  result  is  an  attack  of  indiges- 
tion with  fever,  the  baby  is  made  ill,  and  the  usefulness  of  the  wet- 
nurse  in  the  family  ceases.  These  women  usually  do  best  upon  a 
plain  diet  of  meat,  poultry,  fish,  vegetables,  cereals,  and  milk.  If 
they  are  accustomed  to  taking  beer,  one  bottle  daily  may  be  per- 
mitted. Coffee  may  be  allowed  to  the  extent  of  one  cup  daily,  and 
of  tea  not  more  than  two  cups  should  be  allowed.  Women  of  this 
class  are  almost  invariably  neglectful  of  the  bowel  function,  so  that 
this  must  be  attended  to.  One  free  evacuation  should  take  place 
daily.  As  a  rule,  the  wet-nurse  has  been  accustomed  to  work  and 
will  be  more  contented  and  happy  when  her  time  is  occupied.  Being 
out  of  doors  from  three  to  four  hours  a  day  is  of  decided  advantage 
to  every  nursing  woman.  If  she  possess  sufficient  intelligence  to 
take  the  baby  for  his  outings,  she  should  be  allowed  to  do  so.  For 
the  comfort  of  the  family  it  is  wise  not  to  let  a  wet-nurse  know  her 
full  value.  When  she  feels  that  she  is  indispensable,  trouble  is  apt 
to  follow  from  one  source  or  another.  It  is  particularly  necessary, 
therefore,  that  babies  that  are  wet-nur§ed  should  be  given  one 
bottle-feeding  daily  as  soon  as  they  are  able  to  take  care  of  it.    The 


HUMAN    MILK  75 

wet-nurse  will  then  realize  that  she  can  be  dispensed  with  in  case  of 
misconduct,  or  if  she  leaves  with  an  hour's  notice  the  child  can  be 
given  the  bottle  until  another  nurse  is  secured.  In  the  great  majority 
of  my  cases  it  has  not  been  necessary  to  continue  the  wet-nursing 
after  the  children  are  seven  months  of  age,  for  by  this  time  they  can 
usually  be  fed  on  the  bottle.  Of  course,  unless  her  nursing  proves 
unsatisfactory,  a  wet-nurse  should  not  be  dismissed  at  the  com- 
mencement of  or  during  the  summer. 

HUMAN  MILK 

While  human  milk  varies  as  to  the  proportion  of  its  nutritional 
elements  at  different  periods  of  lactation,  and  even  at  different 
times  of  the  day,  milks  upon  which  infants  thrive  agree  within  cer- 
tain limits,  so  that  a  standard  of  limitations  may  be  laid  down. 
Among  a  great  many  specimens  which  I  have  examined  the  solids 
have  ranged  between  12  and  13  percent.  The  range  in  fat  has  been 
from  2.75  to  4.65  percent,  proteid  from  0.9  to  1.8  percent,  sugar 
from  5.50  to  7.3  percent.  These  figures  represent  the  analyses  of 
the  breast-milks  given  children  who  were  thriving  and  who  were  of 
different  ages.  These  variations  are  not  as  wide  as  have  been 
reported  by  others,  but  it  is  to  be  remembered  that  these  were  all 
babies  who  were  thriving.  Whoever  has  examined  breast-milk 
even  a  few  times  is  aware  of  the  existence  of  the  widest  possible 
variations.  I  have  seen  breast-milks  which  contained  8  percent 
of  fat  and  others  which  contained  only  0.5  percent,  but  children 
thus  fed  were  not  well.  Fat  exists  in  mother's  milk  in  minute  glob- 
ules as  an  emulsion.  It  varies  somewhat  in  composition,  depending 
upon  the  kind  of  food  eaten. 

The  proteids  of  breast-milk  offer  a  wide  field  for  further  study. 
There  are  several  of  these  proteids,  the  most  important  being  casein 
and  lactalbumin.  The  proportions  are  subject  to  considerable 
variation,  depending  upon  the  diet  and  habits  of  life  of  the  producer. 
With  a  continuation  of  lactation  there  is  a  diminution  of  the  pro- 
teid, so  that  at  the  ninth  or  tenth  month  it  is  considerably  reduced, 
the  total  proteid  often  being  not  over  i  percent.  The  sugar  content 
varies  less  than  does  either  the  fat  or  proteid,  its  range  of  limitation, 
even  in  milk  otherwise  poor,  being  not  over  1.5  or  2  percent. 

Directions  for  nursing  well  children  will  be  found  on  page 
62.  As  to  whether  the  child  is  getting  a  sufficient  quantity 
of  milk  may  be  determined  by  weighing  the  baby  before  and  after 
nursing.  For  this  purpose  the  scales  used  for  weighing  children 
should  weigh  accurately  in  one-half  ounces.  The  child  need  not  be 
undressed.  He  is  weighed  when  put  to  the  breast  and  weighed  at 
the  completion  of  the  nursing.  I  have  repeatedly  found  children 
who  should  get  three  ounces  or  more  at  a  feeding  who  after  the 


76 


NUTRITION   AND   GROWTH 


fifteen-minute  nursings  had  increased  in  weight  but  one-half  or  one 
ounce,  showing  that  only  so  much  milk  had  been  taken.  Occasion- 
ally cases  have  been  seen  where  there  was  no  gain  whatever  after 
nursing  and  yet  the  child  was  supposed  to  have  been  fed.  In 
difficult  breast-feeding  it  is  well  personally  to  supervise  a  nursing 
or  two,  by  which  means  much  valuable  information  may  be  gained. 
Examination  of  Human  Milk. — Milk  of  the  mother  is  usually 
examined  to  determine  whether  it  contains  a  sufficient  amount  of 
fat,  sugar,  and  proteid  to  nourish  the  infant ;  or  to  determine  whether 

the  quantity  of  one  or  more  of 
the  nutritional  factors  is  exces- 
sive or  deficient.  Microscopic 
examination  shows  us  little  ex- 
cept the  presence  of  colostrum, 
which  usually  disappears  about 
the  ninth  day  and  is  to  be  con- 
sidered abnormal  if  present 
after  the  twelfth  day.  The 
presence  of  blood  and  pus  may 
also  be  detected  by  the  micro- 
scope. For  an  accurate  analy- 
sis the  milk  should  be  sent  to 
a  laboratory  properly  equipped 
for  such  work.  For  absolute 
accuracy  it  is  not  safe  to  judge 
from  the  analysis  of  one  speci- 
men of  milk;  at  least  two, 
better  three,  specimens  should 
be  analyzed  before  coming  to  a 
conclusion.  In  collecting  milk 
for  examination  the  middle  of 
a  nursing  should  be  selected. 

Laboratory  analysis  is  ex- 
pensive, however,  and  beyond 
the  possibilities  of  many.  For 
out-patient  work  and  those  cases 
in  which  a  determination  of  ap- 
proximate percentages  is  sufficient  I  have  found  the  Holt  milk  set 
(Fig.  8)  of  great  service.  The  set  consists  of  a  lactometer  and 
two  cream-gages.  The  method  of  its  use  is  explained  by  Holt  as 
follows : 

"The  simplest  method  is  by  the  cream-gage.  Although  its 
results  are  only  approximate,  they  are  in  most  cases  sufficiently 
accurate  for  clinical  purposes.  The  tube  is  filled  to  the  zero  mark 
with  freshly  drawn  milk,  which  stands  at  room-temperature  for 
twenty-four  hours,  when  the  percentage  of  cream  is  read  off.     The 


Fig.  8. -The  Holt  Milk  Set. 


CRACKED   AND   FISSURED   NIPPLES 


77 


ratio  of  this  to  the  fat  is  approximately  five  to  three ;  thus  5  percent 
cream  indicates  3  percent  fat,  etc. 

"Sugar. — The  proportion  of  sugar  is  so  nearly  constant  that 
it  may  be  ignored  in  clinical  examinations. 

"  Proteids. — We  have  no  simple  method  for  determining  clinically 
the  amount  of  proteids.  If  we  regard  the  sugar  and  salts  as  con- 
stant, or  so  nearly  so  as  not  to  affect  the  specific  gravity,  we  may 
form  an  approximate  idea  of  the  proteids  from  a  knowledge  of  the 
specific  gravity  and  the  percentage  of  fat.  We  may  thus  determine 
whether  they  are  greatly  in  excess  or  very  low,  which,  after  all,  is 
the  important  thing.  The  specific  gravity  will  then  vary  directly 
with  the  proportion  of  proteids,  and  inversely  with  the  proportion 
of  fat — i.  e.,  high  proteids,  high  specific  gravity;  high  fat,  low  specific 
gravity.  The  application  of  this  principle  will  be  seen  by  reference 
to  the  accompanying  table. ^ 


"WOMAN'S  MILK 

Specific  Gravity,  70°  F. 

Cream— 24  Hours. 

Proteid  (Calculated). 

Average 

Normal    varia- 
tions. . 

1.031 

1.028-1.029 

1.032 

Low  (below  1.028) 

Low  (below  1.028) 

High  (above  1.032) 

High  (above  1.032) 

7  percent. 

8  percent- 12 
percent. 

5    percent-6 

percent. 
High  (above  10 

percent). 
Low    (below  5 

percent) . 
High. 

Low. 

1.5  percent. 
Normal  (rich  milk). 
Normal  (fair  milk). 

Normal  (or  sHghtly  be- 
low). 

Very  low  (very  poor 
milk). 

Very  high  (very  rich 
milk). 

Normal  (or  nearly  so). 

Normal    varia- 

Abnormal    varia- 
tions 

Abnormal    varia- 

Abnormal    varia- 
tions   

Abnormal   varia- 
tions  

"Any  specimen  taken  for  examination  should  be  either  the 
middle  portion  of  the  milk — i.  e. ,  after  nursing  two  or  three  minutes — 
or,  better,  the  entire  quantity  from  one  breast,  since  the  composition 
of  the  milk  will  differ  very  much  according  to  the  time  when  it  is 
drawn.  The  first  milk  is  slightly  richer  in  proteids  and  much  poorer 
in  fat." 

CRACKED  AND  FISSURED  NIPPLES 

Fissures  of  the  nipples  are  often  the  result  of  lack  of  care 
and  cleanliness.  Nipples  that  are  not  washed  and  dried,  but 
allowed  to  remain  moist  after  nursing,  particularly  during  the 
first  few  days,  are  also  very  apt  to  become  macerated  and  cracked. 
In  the  cases  in  which  there  is  a  tendency  for  the  breasts  to  "leak,"  the 
milk  decomposes  on  the  nipples,  and  in  addition  to  the  maceration, 

^The  Holt  apparatus  may  be  obtained  from  Eimer  &  Amend,  Eighteenth 
Street  and  Third  Avenue,  New  York. 


78  NUTRITION   AND   GROWTH 

the  nipple  is  excoriated  by  the  acids  formed  by  the  decomposition 
in  the  milk.  Leaking  nipples  should  be  kept  covered  with  pads  of 
sterile  absorbent  gauze.  Cracks  and  fissures  in  the  nipple  may  be 
sufficiently  painful  to  prevent  a  continuance  of  the  nursing.  In 
getting  the  histories  of  not  a  few  bottle  babies,  I  have  been  told 
that  nursing  had  been  stopped  because  of  cracked  nipples.  The 
prevention  and  successful  treatment  of  the  condition,  therefore,  is 
a  matter  of  no  little  importance.  A  strong  child  tugging  on  a 
fissured  nipple  may  be  an  excruciatingly  painful  process  for  the 
mother,  and  when  the  fissures  are  not  healed,  it  can  readily  be 
understood  that  the  pain  accompanying  and  the  dread  of  nursing 
may  produce  sufficient  mental  distress  to  change  the  character  or 
stop  the  flow  of  the  milk,  either  of  which  may  require  that  the 
nursing  be  discontinued. 

Treatment. — The  treatment  which  gives  the  best  results,  and 
which  is  used  exclusively  at  the  New  York  Infant  Asylum  and 
Maternity,  is  to  bathe  the  parts  with  a  saturated  solution  of 
boric  acid  after  each  nursing,  dry  the  nipple,  and  apply  a  pad 
of  sterile  gauze.  Once  or  twice  a  day,  the  cracks  or  fissures  are 
painted  with  an  8  percent  solution  of  nitrate  of  silver.  There  is  no 
pain  attending  this  application.  The  pad  of  sterile  gauze  just 
referred  to  is  placed  over  the  nipple  and  held  in  position  by  a  binder 
sufficiently  tight  to  support  the  breasts.  Before  the  next  nursing 
the  nipple  is  bathed  with  sterile  water  and  the  infant  takes  the 
breast  as  usual.  If  there  are  deep  fissures,  it  may  be  well  for  a  day 
or  two  to  use  a  nipple- shield.  Another  important  reason  for  a  rapid 
healing,  is  the  danger  of  infecting  the  gland  through  the  open  nipple 
wound — the  usual  cause  of  mammary  abscess.  The  use  of  an 
ointment  to  the  nipples  is  not  advised,  for  the  reason  that  it  is  of 
little  or  no  service;  in  fact,  in  most  cases  ointments  do  harm  because 
they  soften  the  epithelium  and  make  the  nipple  tender. 

CAKING  OF  THE  BREASTS 

Caking  of  the  breasts  is  very  apt  to  occur  during  the  first  few 
days  of  nursing.  The  milk,  when  it  appears  in  the  breasts,  is  often 
secreted  in  large  amount.  A  great  deal  more  is  supplied  than  the 
child,  with  its  small  stomach  and  usually  indifferent  nursing,  is  able 
to  digest.  The  breasts  should  be  watched  very  carefully  during 
this  time  so  as  to  guard  against  the  possibility  of  the  milk  remaining 
undrawn,  with  the  resulting  harm.  After  the  completion  of  the 
regular  nursing,  if  a  considerable  amount  of  milk  remains  in  the 
breasts,  it  should  be  drawn  by  the  breast-pump  (Fig.  9)  and  the 
breast  thus  relieved. 

Treatment. — When  nodules  form,  they  may  readily  be  soft- 
ened by  gentle  massage.  Lanolin  should  be  used  on  the  fingers 
so  as  to  avoid  unnecessary  irritation  of  the  skin.     The  massage 


ACUTE    AND    SUPPURATIVE    MASTITIS    IN    THE    MOTHER  79 

should  be  repeated  as  often  as  the  nodules  appear.  The  caking  is 
more  apt  to  occur  in  the  dependent  portion  of  the  glands.  The 
so-called  pendulous  breasts,  which  may  show  a  tendency  to  cake, 
should  be  supported  by  a  binder  lightly  applied. 

DEPRESSED  NIPPLES 

Not  an  infrequent  source  of  difficulty  in  the  management  of  the 
nursing  function  in  a  primipara  is  depressed  nipples.  The  child 
cannot  get  a  sufficient  hold  to  make  suction  possible.  He  thus 
fails  to  get  the  desired  nutriment,  and  both  the  child  and  the  mother 
become  exhausted  in  consequence.  When  this  is  repeated  a  few 
times,  the  child  is  very  apt  to  refuse  to  make  any  attempt  at  nursing. 
In  such  cases  the  use  of  the  nipple-shield  (Fig.  7)  is  often  indispens- 
able, until  the  nipple  is  sufficiently  drawn  out  and  developed  for 
the  child  to  get  hold  of.  Preceding  each  nursing  it  is  well  to  man- 
ipulate the  nipple  for  a  few  minutes  or  to  elongate  it  by  the  use  of 


i- 


^ii 


I' 


Fig.  9.— English  Breast-pump. 

the  breast-pump  (Fig.  9),  but  not  using  sufficient  force  to  draw  the 
milk. 

ACUTE  AND  SUPPURATIVE  MASTITIS  IN  THE  MOTHER 
When  inflammation  of  the  breast  develops  with  fever,  chills,  and 
prostration,  it  is  usually  the  result  of  an  infection  through  the  nipple, 
generally  one  with  visible  cracks  and  fissures.  The  nursing  of  the 
involved  breast  should  be  discontinued,  for  the  sake  of  both  the 
child  and  the  mother;  in  fact,  the  pain  is  often  so  great  that  nurs- 
ing is  impossible.  A  supporting  bandage  should  be  applied  and 
the  milk  drawn  with  the  breast-pump  at  the  usual  nursing  times. 
It  must  be  our  aim  to  induce  resolution  without  the  formation 
of  pus.  This  is  best  accomplished  by  the  use  of  an  ice-bag 
which  is  kept  constantly  applied  to  the  inflamed,  indurated  area. 
If  there  is  a  tendency  to  constipation,  saline  laxatives  should  be 
used.  With  a  subsidence  of  the  temperature  and  an  abatement  of 
the  inflammation,  nursing  may  be  resumed.     As  soon  as  the  presence 


8o  NUTRITION    AND    GROWTH 

of  pus  is  determined,  it  should  be  removed  regardless  of  its  location 
in  the  gland.  I  have  seen  cases  of  intestinal  infection  in  the  infant 
and  of  infectious  processes  in  other  parts  of  the  body  that  were 
undoubtedly  due  to  its  being  allowed  to  nurse  on  suppurating  breasts. 

SUBSTITUTE   BREAST-FEEDING;    ARTIFICIAL   FEEDING 

A  considerable  number  of  the  young  of  the  human  race  are 
deprived  of  their  natural  means  of  nutrition,  the  milk  of  the  mother. 
For  comparatively  few  is  a  wet-nurse  available.  While  in  proportion 
to  the  children  born  more  mothers  are  nursing  their  infants  now  than 
formerly,  nevertheless  every  year  thousands  of  infants  are  brought 
into  the  world  who  have  to  be  nourished  by  other  means  than  human 
milk.  The  fact  that  an  immense  number  of  deaths  occur  every 
year  among  these  infants  because  of  defective  nutrition  speaks  for 
itself. 

Nutritional  Errors. — Mortality  statistics  give  a  very  inadequate 
idea  as  to  the  part  played  by  nutritional  errors  in  the  young,  for  the 
reason  that  in  many  instances  such  errors  are  not  the  direct  or  perhaps 
the  immediate  cause  of  death,  and  for  this  reason  their  influence  does 
not  appear  in  mortality  statistics.  As  elsewhere  pointed  out,  and 
dwelt  upon  at  length  in  this  work,  in  disease  of  any  nature  a  child's 
resistance  is  a  factor  of  paramount  importance.  With  defective 
nutrition,  resistance  is  invariably  below  the  normal.  Many  of  the 
infants  who  die  from  the  intestinal  diseases  of  summer,  from  grippe, 
from  tuberculosis,  or  from  infectious  diseases,  suffer  from  defective 
nutrition  in  different  degrees  of  severity  before  the  immediate  cause 
of  death  appears. 

The  Needs  of  the  Patient  Paramount. — As  the  nutrition  deals 
directly  with  questions  of  life  and  death,  it  is  not  surprising  that 
volumes  have  been  written  on  the  subject,  but  it  is  surprising  that  the 
fundamental  principles  of  infants'  nutrition  are  so  little  tmderstood. 
This  is  due  in  part  to  the  fact  that  writers  and  teachers  of  infant- feed- 
ing, in  their  efforts  to  be  scientific  or  ultra-scientific,  have  lost  sight 
of  the  point  that  there  is  a  patient  as  well  as  a  pupil  to  be  considered, 
and  that  not  a  few  teachers  with  their  algebraic  or  otherwise  intricate 
formulas  do  little  but  obstruct  the  progress  of  rational  feeding  by 
making  a  readily  comprehended  subject  impossible  to  many.  Another 
common  error  is  in  not  distinguishing  between  children — the  rich 
and  the  poor,  the  sick  and  the  well.  A  child  with  malnutrition,  with 
marasmus,  or  with  a  temporarily  disordered  digestion  is  by  no  means 
a  well  baby,  and  when  he  is  given  food  suitable  only  for  the  well,  his 
condition  very  naturally  is  not  improved. 

Environment. — In  feeding  an  infant,  several  predominant  factors 
must  be  considered :  First,  the  influences  of  environment.  The  infant 
in  a  children's  institution  has  to  be  fed  differently  from  one  who  comes 
to  a  dispensary  for  treatment,  and  both  must  be  fed  differently  in 


SUBSTITUTE    BREAST-FEEDING ;    ARTIFICIAL    FEEDING  8 1 

summer  than  in  winter.  The  child  of  well-to-do,  intelligent  parents 
is  fed  still  differently.  There  are  no  hard  and  fast  lines  in  infant- 
feeding  other  than  that  there  must  be  an  ample  supply  of  such 
nourishment  as  the  child  can  digest  and  thrive  upon.  Cow's  milk 
is  used  as  the  basis  of  infants'  feeding  for  the  reason  that  it  is 
ordinarily  readily  adapted  to  the  child's  digestion  and  is  the  most 
available  human  milk  substitute. 

Successful  Substitute  Feeding. — Successful  substitute  feeding  of 
infants  consists,  then,  in  giving  something  upon  which  the  child  can 
live  and  thrive,  and  when,  in  addition,  this  "something"  supplies 
the  nutrition  which  Nature  demands,  it  constitutes  scientific  infant- 
feeding,  whatever  the  source  of  the  nutriment.  Cow's  milk  is  just 
as  fully  an  unnatural  food  for  an  infant  as  is  barley  or  rice  gruel  or 
the  milk  of  the  goat  or  the  ass,  and  cow's  milk  only  is  used,  as  already 
mentioned,  because  in  a  great  majority  of  cases  it  answers  the  given 
purpose  better  than  does  any  other  food,  in  that  it  furnishes  in 
available  form  the  nearest  approach  to  the  nutritional  elements 
required.  From  an  analysis  of  many  human  milks  we  know  what 
should  constitute  a  child's  food.  Cow's  milk,  however,  differs  from 
human  milk  in  important  features  (page  98). 

Modified  Milk. — The  changing  of  cow's  milk  through  manipu- 
lation so  that  it  may  conform  more  closely  to  human  milk,  and 
consequently  be  more  acceptable  to  the  digestive  capacity  of  the 
child,  has  given  rise  to  the  term  "modified  milk,"  which  is  the 
result  of  a  mechanical  procedure.  The  term  is  a  very  elastic  one, 
and  means  simply  that  the  milk  is  so  changed  that  the  relative 
proportions  of  the  nutritional  elements  correspond  more  nearly 
to  those  of  human  milk.  There  are  other  differences,  however, 
between  cow's  milk  and  human  milk  than  the  simple  matter  of 
the  proportion  of  their  ingredients.  The  principal  difference  is 
in  the  character  of  its  casein.  The  making  of  the  casein  of  cow's 
milk  to  simulate  human-milk  casein  constitutes  practically  what  I 
liave  termed  "milk  adaptation,"  and  will  be  considered  under  that 
heading. 

When  cow's  milk  is  diluted  with  water  and  given  as  a  food  to 
an  infant  he  is  given  "modified  milk."  When  sugar  or  lime-water 
or  a  cereal  gruel  is  added,  it  is  still  modified  milk.  When  a  pre- 
scription is  sent  to  the  laboratory  calling  for  definite  amounts  of 
fat,  sugar,  and  proteid,  the  product  furnished  is  modified  milk. 
When  a  mother  is  told  to  use  a  definite  amount  of  cream,  milk-sugar, 
and  water,  modified  milk  is  the  outcome. 

The  analysis  of  mixed  dairy  milk  shows  it  to  contain  approxi- 
mately : 

4.0  percent  fat; 

4.0  percent  sugar ; 

3.5  percent  total  proteid. 
6 


82  NUTRITION    AND   GROWTH 

Human  milk  contains  approximately : 

4.0  percent  fat ; 

7.0  percent  sugar; 

1.5  percent  total  proteid. 

The  Aim  of  Milk  Modification. — The  first  thought  in  the  modi- 
fication is  grossly  to  make  the  chief  nutritional  elements  in  the  food 
prepared  from  cow's  milk  correspond  to  the  nutritional  elements  in 
the  human  milk.  The  proteid  must  be  reduced,  the  sugar  increased, 
and  the  fat  reduced  even  slightly  below  that  usually  found  in  mother's 
milk,  as  the  child's  digestive  capacity  for  cow"s-milk  fat  is  less  by 
from  15  to  25  percent  than  it  is  for  human  milk. 

The  Proteid. — The  proteid  element  in  an  infant's  food  is  its  chief 
nutritional  content.  This  has  to  be  reduced  to  approximately  the 
proportions  that  exist  in  human  milk,  and  can  be  accomplished  only 
by  dilution.  The  diluent  may  be  plain  water  or  it  may  be  a  cereal 
gruel.     The  average  cow's  milk  contains,  as  just  mentioned: 

4.0 percent  fat; 

4.0  percent  sugar ; 

3.5  percent  total  proteid. 

If  eight  ounces  of  milk  is  mixed  with  eight  ounces  of  water,  we  get 
a  pint  mixture  with  an  approximate  nutritional  equivalent  of : 

2.0    percent  fat; 

2.0    percent  sugar; 

1.75  percent  total  proteid. 

If  four  ounces  of  milk  is  mixed  with  twelve  ounces  of  water  we  have 
a  sixteen-ounce  mixture  with  an  approximate  nutritional  equivalent 
of: 

i.o  percent  fat; 

i.o  percent  sugar; 

0.9  percent  total  proteid. 

If  six  ounces  of  milk  is  mixed  with  ten  ounces  of  water  a  sixteen- 
ounce  mixture  is  produced  with  an  approximate  nutritional  equiva- 
lent of: 

1.5  percent  fat; 

1.5  percent  sugar; 

1.3  percent  total  proteid. 

By  this  simple  dilution  with  water  it  may  be  seen  that  the  desired 
proteid  content  of  the  food  may  be  arrived  at. 

The  Sugar. — For  nourishment  for  an  infant,  however,  the  mixture 
is  weak  in  fat  and  very  weak  in  sugar.  The  sugar  content  is  increased 
by  the  addition  of  milk-sugar  or  cane-sugar.     It  will  be  remembered 


substitute;  breast-feeding;  artificial  feeding 


83 


that  with  human  milk  there  is  a  sugar  content  of  7  percent.  The 
combination  of  full  cow's  milk  and  water  as  above  gives  a  sugar 
content  of  2  percent  or  less,  so  that  sufficient  sugar  must  be  added 
to  make  the  increase  approximately  7  percent.  What  is  necessary, 
then,  is  to  increase  the  sugar  content  5  percent.  A  i  percent  sugar 
and  water  mixture  would  contain  approximately  five  grains  of  sugar 
to  the  ounce.  A  6  percent  sugar  mixture  would  contain  thirty 
grains  to  the  ounce,  and  as  our  dealings  are  with 
a  sixteen-ounce  mixture  we  will  require  an  addi- 
tion of  sixteen  times  thirty  grains  of  sugar  of  milk, 
or  480  grains,  so  that  if  we  direct  that  a  pint  mix- 
ture contain  6  ounces  of  a  4,  4,  3.50  milk,  10  ounces 
water,  i  ounce  milk-sugar,  there  would  be  an  ap- 
proximate nutritional  equivalent  of : 

1.5  percent  fat; 

7.5  percent  sugar; 

1.3  percent  total  proteid. 

Or  if  it  were  4  ounces  milk,  12  ounces  water,  i 
ounce  milk-sugar,  there  would  be  a  nutritional 
equivalent  of; 

1 .0  percent  fat ; 

7.0  percent  sugar; 

0.9  percent  total  proteid. 

The  Fat. — While  a  child  of  from  two  to  four 
months  might  thrive  on  the  above  formulas,  the 
fat  is  obviously  deficient  and  needs  to  be  increased. 
This  is  accomplished  by  the  use  of  cream. 
Cream  of  the  same  age  as  the  milk  should  be 
used.  When  this  method  of  feeding  is  carried 
out,  in  order  to  secure  a  suitable  cream,  a  quart 
bottle  of  milk  from  a  mixed  herd  of  grade  cows 
is  allowed  to  stand  at  a  temperature  of  40°  or 
50°  F.  for  five  hours,  when  a  cream  will  be  pro- 
duced of  the  approximate  strength  of : 

16.0  percent  butter  fat; 
3.2  percent  sugar; 
3.2  percent  total  proteid. 

Cream  from  well-fed  Jersey  cows  procured  in  this 

way  will  contain  from   20  to  24  percent  of  fat. 

These  were  the  percentages  obtained  in  an  analysis  made  for  me 

from  the  Walker-Gordon  Laboratory  milk,  which   is  produced  by 

grade  cows  and  represents  an  average  milk  strength  as  regards  the 

nutritional  elements,  and  may  therefore  be  taken  as  a  guide  in  using 

gravity  cream  for  infant-feeding.     One  ounce  of  gravity  cream  with 


Fig.  10.— The  Chapin- 
Dipper. 


84  NUTRITION    AND    GROWTH 

fifteen  ounces  of  water  gives  a  pint  mixture  with  a  nutritional 
equivalent  of: 

I  .o  percent  fat ; 

0.2  percent  sugar; 

0.2  percent  total  proteid. 

Two  ounces  of  gravity  cream  and  fourteen  ounces  of  water  give  an 
approximate  nutritional  equivalent  of : 

2.0  percent  fat; 

0.4  percent  sugar; 

0.4  percent  total  proteid. 

We  now  wish  by  using  gravity  cream  to  raise  the  fat  in  the  milk 
and  sugar-water  mixtures  given  above.  In  using  the  cream  all 
must  be  removed  and  mixed,  as  the  upper  layers  are  much  richer 
in  fat  than  those  nearer  the  milk.  For  this  skimming  process  the 
Chapin  dipper  (Fig.  10)  is  employed.  Milk  which  is  rapidly  cooled 
immediately  after  being  drawn  and  kept  at  a  temperature  of  50°  F. 
or  lower  ma}'  be  skimmed  at  the  end  of  five  hours,  when  all  the 
cream  that  will  rise  will  have  done  so. 

Illustrative  Food  Formulas. 

Gravity  cream 1  ounce  Approximate  Percentage  Equivalent. 

Milk 4  ounces         Fat 2.0 

Milk-sugar 1  ounce  Sugar 7.2 

Water II  ounces         Total  proteid 1.1 

Gravity  cream 2  ounces  Approximate  Percentage  Equivalent. 

Milk 4  ounces         Fat 3.0 

Milk-sugar 1  ounce  Sugar 7.4 

Water 10  ounces         Total  proteid 1.3 

In  the  event  of  a  weak  proteid  digestion  in  a  young  baby,  gravity 
cream  alone  may  be  used  temporarily ;  thus  3  ounces  cream,  i  ounce 
milk-sugar,  12  ounces  water,  i  ounce  lime-water,  which  mixture 
gives  an  approximate  nutritional  equivalent  of: 

3.0  percent  fat; 

6.6  percent  sugar; 

0.6  percent  total  proteid. 

Or  if  a  weaker  food  is  desired  for  a  younger  infant,  we  may  use 
2  ounces  gravity  cream,  i  ounce  milk-sugar,  13^  ounces  water, 
^  ounce  lime-water,  which  mixture  gives  an  approximate  equiva- 
lent of: 

2.0  percent  fat; 

6.4  percent  sugar; 

0.4  percent  total  proteid. 

In  the  event  of  a  good  proteid  digestion  and  poor  fat  digestion,  full 
milk  alone  with  sugar  and  water  is  to  be  used ;  thus  5^  ounces  milk, 


SUBSTITUTE   breast-feeding;    ARTIFICIAL   FEEDING  85 

TO  ounces  water,  i  ounce  milk-sugar,  1 5  ounces  lime-water,  which 
mixture  gives  an  approximate  equivalent  of: 

1.33  percent  fat; 

7.33  percent  sugar; 

1 .  1 7  percent  total  proteid. 

Average  skimmed  milk  with  the  gravity  cream  removed  contains 
about  I  percent  fat,  3.5  percent  sugar,  and  3  percent  proteid.  If 
for  any  reason  a  particularly  weak  fat  food  is  required,  skimmed 
milk  may  be  used:  5-3  ounces  skimmed  milk,  9  ounces  water,  i  ounce 
milk-sugar,  if  ounces  lime-water,  which  mixture  gives  an  approxi- 
mate equivalent  of : 

0.30  percent  fat; 

7.15  percent  sugar; 

1 .00  percent  total  proteid. 

If  a  stronger  skimmed  milk  mixture  is  required,  it  may  be  pre- 
pared as  follows:  8  ounces  skimmed  milk,  8  ounces  water,  i  ounce 
milk-sugar,  which  mixture  gives  an  approximate  nutritional  equiva- 
lent of: 

0.50  percent  fat; 

7.75  percent  sugar; 

1.50  percent  total  proteid. 

It  will  thus  be  seen  that  with  milk,  cream,  and  sugar  of  milk  every 
possible  form  of  food  strength  may  be  made.  If  lime-water  is  used, 
it  simply  takes  the  place  of  the  milk  diluent  and  replaces  so  much 
water.  This  method  of  milk  preparation  is  more  accurate  than 
when  top-milk  mixtures  are  used,  but  it  has  the  disadvantage  of 
requiring  two  quarts  of  milk  during  the  entire  feeding  period,  one 
to  supply  the  milk  and  the  other  the  cream,  all  of  which  must  be 
removed  and  mixed  before  any  of  it  is  used  in  the  food. 

The   following  formulas  for   the  different   ages   may  be   found 
useful  for  well  babies: 

From  the  first  to  the  third  day: 

Milk-sugar J  ounce 

Boiled  water 16     ounces 

I  to  1  ounce  every  two  or  three  hours; 

which  mixture  gives  an  approximate  nutritional  equivalent  of 
3  percent  sugar. 

From  the  third  to  the  tenth  day: 

Gravity  cream h  ounce  Approximate  Percentage  Equivalent. 

Milk 3"   ounces  Fat 1.25 

Milk-sugar 1     ounce  Sugar 6.7 

Lime-water h  ounce  Total  proteid 0.66 

Boiled  water  to  make 16     ounces 

Ten  feedings  in  twenty-four  hours ;  1  to  H  ounces  at  each  feeding. 


86  NUTRITION    AND   GROWTH 

From  the  tenth  to  the  twenty-first  day: 

Gravity  cream l;f   ounces  Approximate  Percentage  Equivalent. 

Milk 5     ounces         Fat 1.66 

Milk-sugar 1 J  ounces         Sugar 6.8 

Lime-water h  ounce  Total  proteid 0.74 

Water  to  make 24     ounces 

Ten  feedings  in  twenty-four  hours ;  1  ^  to  2  ounces  at  each  feeding. 

From  the  third  to  the  sixth  week: 

Gravity  cream 2^  ounces  Approximate  Percentage  Equivalent. 

Milk 8     ounces  Fat 2.25 

Milk-sugar 2     ounces  Sugar 7.0 

Lime-water 2     ounces  Total  proteid 0.9 

Water  to  make 32     ounces 

Nine  feedings  in  twenty-four  hours ;  2  to  3  ounces  at  each  feeding. 

From  the  sixth  week  to  the  third  month: 

Gravity  cream 3      ounces  Approximate  Percentage  Equivalent. 

Milk 9     ounces         Fat 2.6 

Milk-sugar 2     ounces         Sugar 7.1 

Lime-water 2h  ounces         Total  proteid 1.0 

Water  to  make '. 32     ounces 

Eight  feedings  in  twenty-four  hours;  2 J  to  4  ounces  at  each  feeding. 

From  the  third  to  the  fifth  month: 

Gravity  cream 4     ounces  Approximate  Percentage  Equivalent. 

Milk 15     ounces         Fat 3.1 

Milk-sugar 2^  ounces         Sugar 7.5 

Lime-water 4     ounces         Total  proteid 1.3 

Water  to  make 40     ounces 

Eight  feedings  in  twenty-four  hours ;  4  to  5  ounces  at  each  feeding. 

From  the  fifth  to  the  seventh  month: 

Gravity  cream 5      ounces  Approximate  Percentage  Equivalent. 

Milk 18     ounces         Fat 3.6 

Milk-sugar 2|  ounces         Sugar 7.6 

Lime-water 5     ounces         Total  proteid 1.5 

Water  to  make 42     ounces 

Six  to  seven  feedings  in  twenty-four  hours ;  5  to  7  ounces  at  each  feeding. 

After  the  fifth  month  it  is  my  custom  to  add  from  one  to  three  tea- 
spoonfuls  of  a  cereal  jelly  to  each  feeding.  This  may  be  added  to  the 
milk  mixture  when  it  is  made  in  the  morning.  Thus,  if  one  teaspoon- 
ful  is  to  be  given  at  each  feeding  v^here  a  child  is  getting  six  feedings, 
six  teaspoonfuls  of  the  jelly  may  be  added  to  the  entire  quantity. 

From  the  seventh  to  the  ninth  month: 

Gravity  cream 6     ounces  Approximate  Percentage  Equivalent. 

Milk 23     ounces         Fat 3.9 

Milk-sugar 2^  ounces         Sugar 7.1 

Lime-water 6     ounces         Total  proteid 1.7 

Water  to  make 48     ounces 

Five  to  six  feedings  in  twenty-four  hours ;  6  to  8  ounces  at  each  feeding. 


SUBSTITUTE    BREAST-FEEDING;    ARTIFICIAL   FEEDING  87 

From  the  ninth  to  the  twelfth  -month: 

Gravity  cream 7      ounces  Approximate  Percentage  Equivalent. 

Milk 32     ounces         Fat 4.28 

Lime-water 6     ounces         Sugar 7.6 

Milk-sugar 3     ounces         Total  proteid 2.0 

Water  to  make 56     ounces 

Five  to  six  feedings  in  twenty-four  hours ;  7  to  9  ounces  at  each  feeding. 

Top -milk  Feeding. — In  using  top  milks  for  infant- feeding  the 
milk  is  allowed  to  stand  in  a  quart  bottle  at  a  temperature  of  45°  to 
50°  F.  for  the  same  length  of  time  as  when  gravity  cream  is  desired — 
five  hours — when  the  quantity  needed  is  removed  from  the  top  of 
the  bottle  with  a  Chapin  dipper  (Fig.  10)  and  diluted  as  desired 
with  water  or  gruel  to  which  sugar  of  milk  and  lime-water  are 
added.  The  milk  selected  should  be  the  cleanest  obtainable  from 
grade  cows;  usually  the  most  expensive  is  the  best.  If  so-called 
"certified  milk"  (page  103)  is  obtainable,  it  should  be  used,  as  this 
warrants  a  cleaner  food  than  that  furnished  by  the  usual  market 
milks. 

From  a  quart  bottle  of  milk  in  which  the  cream  has  risen,  dip 
off  from  the  top  with  a  Chapin  dipper  sixteen  ounces  and  mix.  From 
average  milk  this  should  contain: 

7.0  percent  fat; 

3.2  percent  sugar; 

3.2  percent  total  proteid. 

The  following  formulas  are  suggested  for  the  various  ages  noted : 
From  the  third  to  the  tenth  day: 

Top  milk 3      ounces  Approximate  Percentage  Equivalent. 

Lime-water 2  ounce  Fat 1.3 

Milk-sugar 1     ounce  Sugar 6.6 

Boiled  water  to  make 16     ounces         Total  proteid 0.6 

Ten  feedings  in  twenty-four  hours;  1  to  H  ounces  at  each  feeding. 

From  the  tenth  to  the  twenty-first  day: 

Top  milk 6      ounces  Approximate  Percentage  Equivalent. 

Lime-water H  ounces         Fat 1-7 

Milk-sugar U  ounces         Sugar 6.8 

Water  to  make 24     ounces         Total  proteid 0.8 

Ten  feedings  in  twenty-four  hours ;  1 J  to  2  ounces  at  each  feeding. 

From  the  third  to  the  sixth  week: 

Top  milk  10      ounces  Approximate  Percentage  Equivalent. 

Lime-water 2^  ounces         Fat 2.2 

Milk-sugar 2     ounces         Sugar 7.0 

Water  to  make 32     ounces         Total  proteid 1-0 

Nine  feedings  in  twenty-four  hours ;  2  to  3  ounces  at  each  feeding. 

From  the  sixth  week  to  the  third  month: 

Too  milk                                             12      ounces  Approximate  Percentage  Equivalent. 

Milk-sugar 2     ounces         Fat 2.6 

Lime-water 3     ounces         Sugar 7.2 

Water  to  make 32     ounces         Total  proteid 1.2 

Eight  feedings  in  twenty-four  hours;  2 J  to  4  ounces  at  each  feedmg. 


88  NUTRITION   AND   GROWTH 

From  the  third  to  the  fifth  month: 

Top  milk 18     ounces  Approximate  Percentage  Equivalent. 

Milk-sugar 2h  ounces         Fat 3.1 

Lime-water 4     ounces         Sugar 7.4 

Water  to  make 40     ounces         Total  proteid 1.4 

Eight  feedings  in  twenty-four  hours;  4  to  5  ounces  at  each  feeding. 

From  the  fifth  to  the  seventh  month: 

After  this  age  two  bottles  of  milk  are  required,  i6  ounces  being 
taken  from  the  top  of  two  bottles  and  mixed : 

Top  milk 21       ounces  .\pproximate  Percentage  Equivalent. 

Milk-sugar 2^  ounces         Fat 3.50 

Lime-water 5     ounces         Sugar 7.5 

Water  to  make 42     ounces         Total  proteid 1.6 

Six  to  seven  feedings  in  twenty-four  hours ;  5  to  7  ounces  at  each  feeding. 

From  the  seventh  to  the  ninth  month: 

Top  milk 27      ounces  Approximate  Percentage  Equivalent. 

Milk-sugar 2 J  ounces         Fat 3.93 

Lime-w'ater 6     ounces         Sugar 7 

Water  to  make 48     ounces         Total  proteid 1.8 

Five  to  six  feedings  in  twenty-four  hours ;  6  to  8  ounces  at  each  feeding. 

From  the  ninth  to  the  twelfth  vwnth: 

Top  milk 35      ounces  Approximate  Percentage  Equivalent. 

Milk-sugar 3     ounces         Fat 4.3 

Lime-water 6     ounces         Sugar 7.3 

Water  to  make 56     ounces         Total  proteid 2.0 

Five  to  six  feedings  in  twenty-four  hours ;  7  to  9  ounces  at  each  feeding. 

After  the  twelfth  month,  plain  cow's  milk  may  be  given  with  the 
cereal  jelly  in  addition  to  the  other  articles  of  diet  suggested  for 
a  child  one  year  old.     (See  page  128.) 

It  will  be  noticed  that  considerable  latitude  is  allowed  as  to 
the  amount  of  food  which  may  be  given  at  each  feeding.  This  is 
because  of  the  difference   in  the   capacity  of   individual  children. 

Night  Feedings. — After  the  third  month  the  midnight  feeding 
should  be  discontinued.  Seven  feedings  will  be  sufficient,  the  first 
at  6  A.  M.  and  the  last  at  10.30  or  11  p.  m. 

Between  11  p.  m.  and  6  a.  m.  the  child  should  sleep.  Babies 
are  easily  broken  from  the  night  bottle  by  substituting  a  bottle  of 
boiled  water  or  a  milk  mixture  greatly  diluted  wdth  water.  The 
child  soon  discovers  that  this  is  not  worth  waking  for.  As  a  restilt 
of  a  full  night's  rest  the  digestive  organs  are  better  able  to  do  their 
work,  the  appetite  is  increased,  and  a  larger  amount  of  food  may  be 
given  at  each  feeding. 

Changes  Needed  for  Special  Symptoms. — When  the  milk  does 
not  agree,  the  cause  must  be  discovered.  The  food  as  a  whole 
may  be  too  strong,  when  there  will  be  indigestion  and  colic,  and 
possibly  diarrhea  and  vomiting.     If  the  food  contains  too  much  fat, 


SUBSTITUTE    BRKAST-FEEDING;    ARTIFICIAL   FEEDING  89 

there  will  be  loosoiess  of  the  bowels  and  colicky  stools,  with  con- 
siderable straining,  and  there  is  apt  to  be  regurgitation  also.  The 
sugar  is  rarely  a  cause  of  trouble,  indications  of  excess  being  the 
eructation  of  gas  and  a  regurgitation  of  sour,  watery  material.  It  is 
comparatively  rare,  however,  for  the  fat  and  sugar  to  cause  any 
disturbance  if  they  are  given  with  any  degree  of  intelligence ;  but 
the  casein,  the  curd-forming  element  in  cow's  milk,  often  gives  us 
no  end  of  trouble.  Many  infants,  as  previously  stated,  are  able  to 
digest  only  a  very  weak  cow's-milk  casein;  consequently,  at  the 
beginning  of  cow's-milk  feeding,  when,  as  is  often  the  case,  too 
much  milk  is  used — too  strong  a  food  given — the  result  is  always 
disastrous.  This,  with  too  frequent  feedings  and  night  feedings, 
comprise  the  chief  errors  made  in  cow's-milk  feeding — in  fact,  they 
are  the  cause  of  more  bottle-feeding  failures  than  all  other  factors 
combined. 

The  Quality  of  Milk  Variable. — It  is  not  claimed  that  the  nutri- 
tional value  as  indicated  by  the  percentage  equivalents  in  either  of 
the  above  series  is  absolutely  correct.  Milks  necessarily  differ  in  com- 
position. Only  mixed  dairy  milk  is  referred  to,  the  product  of  several 
grade  cows.  The  feeding  of  the  cows  and  their  care  also  influence  the 
quality  of  the  milk.  The  percentages  indicated  give  approximately 
the  nutritional  value  and  are  sufficiently  accurate  for  purposes  of 
supplying  satisfactory  nutrition  to  well  babies  of  the  various  ages,  as  I 
have  abundantly  proved  to  my  own  satisfaction.  The  fats  will  not  be 
found  too  low  for  proper  nutrition  in  any  of  the  formulas  given. 
They  may  be  too  high  for  proper  digestion  and  require  adjustment. 
The  proteids  as  given  are  sufficient  for  nutrition  if  they  are  assimi- 
lated. They  also  may  require  reduction  to  meet  special  conditions 
which  are  referred  to  under  Milk  Adaptation  (page  94).  The  adjust- 
ment of  the  food  to  the  individual,  constitutes  what  I  have  termed 
"Milk  Adaptation,"  and  suggestions  for  making  the  food  fit  the 
child's  digestive  capacity  will  be  found  under  that  caption. 

Laboratory  Feeding. — To  Rotch,  of  Boston,  we  are  indebted  for 
the  establishment  of  the  practice  of  thinking  in  percentages  in  the 
feeding  of  infants  and  for  the  establishment  of  milk  laboratories 
which  mark  an  epoch  in  the  feeding  of  infants.  Haphazard  methods 
of  feeding  have  been  superseded  by  methods  which  rest  upon  a 
scientific  basis.  The  change  for  the  better  has  been  slow  but  effec- 
tual, so  that  all  who  now  teach  or  practise  pediatrics  successfully 
must  think  in  percentages  and  feed  accordingly.  The  advantages 
of  using  the  milk  of  a  properly  conducted  laboratory  are  accuracy 
in  the  nutritional  content  in  the  food  furnished  and  cleanliness. 
It  also  lightens  the  household  duties,  the  milk  being  delivered  every 
morning  ready  for  use.  The  physician  sends  the  prescription  to  the 
laboratory  on  such  a  prescription  blank  as  that  shown  on  page  90. 


90 


NUTRITION    AND   GROWTH 


Fat 

Milk-sugar 
Proteids  .  . 
Lime-water 
Diluent .  .  . 


Number  of 
feedings 

Amount  of 
each  feeding 


In  Qt.  Jar- 
Heat  to 


Ordered  for- 


Date 


Signature 


-M.D. 


The  milk  thus  is  dehvered  in  quart  bottles  or  in  as  many  nursing 
bottles  as  there  are  feedings  in  twenty-four  hours,  each  bottle  con- 
taining the  number  of  ounces  called  for. 

A  further  advantage  possessed  by  the  laboratory  is  that  in  very 
difficult  cases  of  proteid  feeding  a  finer  adjustment  is  possible  than 
is  the  case  with  home-made  preparations,  a  very  valuable  aid  in  the 
feeding  of  such  cases.  A  splitting  up  of  the  proteid  by  using  whey 
proteid  is  here  more  accurately  accomplished  than  is  possible  in  the 
home.  Unfortunately,  the  product  of  milk  laboratories,  on  account 
of  the  expense  of  equipment  and  maintenance,  together  with  the 
expense  of  producing  a  high-grade  milk  at  the  farm,  is  rendered  so 
expensive  to  the  consumer  that  it  is  available  to  comparatively  few. 

A  Convenient  Means  for  Home  Modification. — A  measuring 
glass  has  recently  been  placed  on  the  market,  known  as  the 
Deming  percentage  milk  modifier  (Fig.  ii).  The  device  is  a  pint 
graduate  provided  with  a  column  of  figures  in  red  representing 
percentages  of  proteid,  and  several  other  columns  representing 
percentages  of  fat.  The  fat  percentages  in  one  column  are  to 
be  obtained  by  using  whole  milk,  in  another  7  percent  milk,  in 
another  10  percent,  etc.  At  the  head  of  each  column  are  direc- 
tions showing  how  such  a  milk  may  be  obtained  from  a  quart  bottle 
of  milk.  The  figures  representing  proteid  percentages  are  so  placed 
on  the  glass  that  when  milk  is  poured  into  the  graduate  up  to  the 
level  of  any  set  of  figures  and  diluent  added  up  to  the  sixteen-ounce 
mark,  the  resulting  mixture  will  contain  a  percentage  of  proteid 
corresponding  to  the  red  figure  at  the  first  level  and  a  percentage 
of  fat  corresponding  to  the  figures  at  that  level  in  the  column  which 
represents  the  kind  of  milk  used.  For  example,  if  whole  milk  is 
poured  in  up  to  the  red  (proteid)  mark  2  and  diluent  added  to  sixteen 


SUBSTITUTE  breast-feeding;  artikiciae  feeding 


91 


■ounces,  the  fat  percentage  will  be  2.5,  which  is  the  figure  at  the  same 
level  as  the  proteid  percentage,  and  under  the  whole-milk  column. 
Or  if  7  percent  milk  is  used,  4.4  percent,  and  if  10  percent,  6.2  per- 
cent, etc. 

The  Feeding  of  Dispensary  Patients. — The  feeding  of  cow's 
milk  according  to  one  or  more  of  the  above  methods  is  the 
best  means  of  furnishing  infant  nutrition.  The  laboratory,  the 
milk  and  cream,  or  the  top-milk  methods  all  pediatrists  are 
agreed  have  proved  the  best  means  of  applying  substitute  feed- 
ing. That  a  great  majority  of  infants  may  be  fed  in  this  way, 
if  they  are  properly  handled  by  a  suitable  adjustment,  there  is  not 
the  slightest  doubt,  but  where  there  is  a  majority,  there  is  also  a 
minority,  and  a  goodly  portion  of 
this  minority  who  reside  in  large 
cities  and  the  suburbs  of  large  cities 
fall  into  the  hands  of  the  pediatrist 
either  in  hospital,  in  out-patient,  or 
in  private  w^ork.  Economic  ques- 
tions oftentimes  govern  the  selec- 
tion of  the  food.  Physicians  who 
Tiave  an  invariable  system  of  feed- 
ing must  of  necessity  have  but  one 
type  of  patients  to  deal  with. 

As  loud  as  we  may  be  in  our 
advocacy  of  the  ennobling  principles 
of  democracy,  we  cannot  treat  alike, 
as  regards  their  feeding,  all  well  chil- 
dren even  in  private  practice.  The 
•child  of  a  stupid  mother  cannot  be 
fed  as  well  or  in  the  same  way  as 
the  child  of  a  reasonably  intelligent 
mother  in  the  same  station  of  life. 
An  infant  of  a  very  poor  mother, 
whether  she   is   dull  or   intelligent, 

cannot  be  fed  to  the  infant's  best  advantage,  for  the  reason — a  very 
simple  but  effectual  one — that  the  mother  cannot  afford  cow's  milk 
Among  the  out-patient  class  in  New  York  city,  the  expensive  milk 
is  therefore  entirely  out  of  the  question.  I  have  treated  many  infants 
whose  parents  could  not  expend  eight  cents  daily  for  a  quart  of  milk. 

The  Patient's  Limitations  and  How  to  Meet  Them.— The  Straus 
laboratories,  which  supply  pasteurized  milk  to  the  poor  of  New 
York  city,  excellent  as  they  are,  are  available  to  comparatively 
few.  Milk  and  cream  combinations  are  impossible  oftentimes  be- 
cause of  expense  or  because  of  inability  to  appreciate  and  carry 
out  the  details  required  for  their  proper  use,  so  that  in  the  out- 
patient poor  class  we  have  to  feed  either  by  top-milk  methods  or 


Fig.  II.— Deming's  Milk  Modifier. 


92  NUTRITION    AND   GROWTH 

by  the  simple  dilution  of  full  milk  with  water  and  sugar  or  with  a 
cereal  gruel  and  sugar,  while  for  the  very  poor,  those  who  cannot 
afford  cow's  milk  and  ice,  we  are  forced  to  use  condensed  milk. 
The  top-milk  method  is  available  to  but  comparatively  few  of 
these  mothers,  even  though  the  directions  are  carefully  explained 
and  printed  instructions  used.  The  use  of  top  milks  with  many, 
while  the  method  is  very  simple,  is  not  readily  understood,  and  it 
has  usually  been  unsatisfactory.  The  dipper,  a  useful  portion  of  the 
equipment,  makes  an  extra  utensil  to  be  kept  clean.  Women  who 
do  all  their  own  housework,  take  care  of  their  own  children,  and 
perhaps  take  in  outside  work  have  but  little  time  for  attention  to 
the  details  of  infant-feeding.  The  easiest  way,  naturally,  has  for 
them  many  attractions.  Among  these  patients  mv  best  success 
has  been  in  the  use  of  full  milk.  They  know  how  to  shake  the  bottle 
and  measure  out  the  milk  and  mix  it  with  water  or  barley-water, 
in  the  amount  to  be  fed  to  the  baby.  Further  than  this,  their 
comprehension  frequently  does  not  extend,  and,  again,  this  is  very 
easily  done. 

As  will  readily  be  perceived,  the  feeding  of  diluted  full  milk 
gives  a  food  poor  in  fat.  This  we  endeavor  to  make  up  by  using 
three  times  a  day  one-half  teaspoonful  or  one  teaspoonful  of  pure 
cod-liver  oil,  for  which  there  is  no  charge  at  the  dispensary. 

The  following  formulas  and  instructions  for  bottle-feeding  are 
taken  from  the  Rules  for  the  Care  of  Infants  and  Young  Children 
which  are  used  in  my  service  at  the  out-patient  department  of  the 
Babies'  Hospital,  and  give  the  simplest  and  easiest  means  of  bottle- 
feeding. 

"  Bottlc-fccdinq:  The  bottle  should  be  thoroughlv  cleansed 
with  borax  and  hot  water  (one  tablespoonful  of  borax  to  a  pint  of 
water)  and  boiled  before  using.  The  nipple  should  be  turned  inside 
out,  scrubbed  with  a  brush,  using  hot  borax  water.  The  brush 
should  be  used  for  no  other  purpose.  The  bottle  and  nipple 
should  rest  in  plain  boiled  water  until  wanted.  Never  use  grocery 
milk.  Use  only  bottled  milk  which  is  delivered  every  morning. 
From  May  ist  to  October  ist  the  milk  should  be  boiled  five  minutes 
immediately  after  receiving.  Children  of  the  same  age  vary  greatly 
as  to  the  strength  and  amount  of  food  required.  A  mixture,  when 
prepared,  should  be  put  in  a  covered  glass  fruit- jar  and  kept  on  the 
ice.  For  the  average  baby  the  following  mixtures  will  be  foimd 
useful : 

"  For  a  child  under  six  weeks  of  age:  Nine  ounces  of  milk,  twenty- 
seven  ounces  of  barley-water,  four  teaspoonfuls  of  granulated 
sugar.  Feed  from  two  to  three  ounces  at  two  and  one-quarter- 
hour  intervals,  nine  feedings  in  twenty-four  hours. 

"Sixth  to  the  twclftJi  week:  Twelve  ounces  milk,  twenty-four 
ounces  barley-water,  five  teaspoonfuls  sugar.  Feed  from  three 
to  four  ounces  at  each  feeding. 

"Third   to   the   sixth    month:     Eighteen   ounces   of   milk,    thirty 


SUBSTITUTE    BREAST-FEEDING;    ARTIFICIAL    FEEDING  93 

ounces  of  barley-water,  six  teaspoonfuls  of  sugar.     Feed  four  to  six 
ounces  at  three-hour  intervals,  seven  feedings  in  twenty-four  hours. 

''Sixth  to  the  ninth  month:  Twenty-four  ounces  milk,  twenty- 
four  ounces  barley-water,  six  teaspoonfuls  granulated  sugar.  Feed 
six  to  eight  ounces  at  three-hour  intervals,  six  feedings  in  twenty- 
four  hours. 

''Ninth  to  twelfth  month:  Thirty-eight  ounces  milk,  twelve 
ounces  barley-water,  six  teaspoonfuls  of  granulated  sugar.  Feed  seven 
to  nine  ounces  at  three  and  one-half  hour  intervals,  five  feedings 
in  twentv-four  hours. 

"Condensed  Milk:  When  the  mother  cannot  afford  to  buy 
bottled  milk  from  the  wagon,  when  she  has  no  ice-chest  or  cannot 
afford  to  buy  ice,  she  should  not  attempt  cow's-milk  feeding,  but 
may  use  canned  condensed  milk  as  a  substitute  during  the  hot  months 
only.  The  can,  when  opened,  should  be  kept  in  the  coolest  place 
in  the  apartment,  carefully  wrapped  in  clean  white  paper  or  in  a 
clean  towel.  The  feeding  hours  are  the  same  as  for  fresh  cow's 
milk. 

"  Under  three  months  of  age:  Condensed  milk  one-half  to  one 
teaspoonful ;  barlev- water,  two  to  four  ounces. 

"  Third  to  sixth  month:  Condensed  milk,  one  to  two  teaspoonfuls ; 
barley-water,  four  to  six  ounces. 

"Sixth  to  ninth  month:  Condensed  milk,  two  to  three  teaspoon- 
fuls ;  barley-water,  six  to  eight  ounces. 

"Ninth  to  twelfth  month:  Condensed  milk,  three  teaspoonfuls; 
barley-water,  eight  to  nine  ounces." 

A  cereal  water  is  used  as  a  diluent  in  all  of  these  cases,  as  it 
increases  the  nutritional  value  of  the  food.  One-half  ounce  barley 
flour  to  a  pint  of  water  gives  a  nutritional  equivalent  of: 

0.07  percent  fat ; 

0.3    percent  total  proteid; 

2.0    percent  carbohydrate. 

Changes  Needed  in  Hot  Weather.— It  wdll  be  seen  that  the 
foregoing  whole-milk  formulas  are  poor  in  fat,  as  previously  stated, 
but  during  the  hot  months  they  contain  as  much  fat  as  the  aver- 
age tenement  child  can  safely  digest  without  danger  of  producing 
diarrhea.  During  the  cooler  months  of  the  year  the  child  is  given 
pure  cod-liver  oil  from  the  dispensary  in  order  to  make  up  for 
the  deficient  fat  content  of  the  food.  During  the  eight  months 
from  October  ist  to  June  ist  the  child  is  fed  in  this  way.  About 
June  I  St  the  conditions  of  the  family  are  investigated  as  to  their 
ability  to  care  for  the  milk  during  the  hot  weather.  If  they  have 
ice-boxes  and  can  afford  ice  they  are  instructed  to  continue  with  the 
milk,  but  instead  of  giving  it  raw,  as  previously,  they  are  told  to 
boil  it  three  minutes.  When  they  cannot  supply  sufficient  ice  to 
care  for  the  milk,  they  are  put  into  the  condensed-milk  class.  A 
fairly  satisfactory  infant  milk  may  be  obtained  in  New  York  city 


94  NUTRITION    AND   GROWTH 

for  eight  cents  a  quart.  There  are  parents  in  New  York,  however^ 
who  cannot  afford  even  this  daily  expenditure  for  the  infant's  milk, 
or  who  claim  that  they  cannot,  which  amounts  to  the  same  thing, 
as  far  as  the  infant  is  concerned.  The  infant  has  to  be  fed.  A 
ten-cent  can  of  condensed  milk  will  last  an  infant  three  days,  and 
it  will  keep  safely  for  use  for  that  length  of  time  after  opening.  It  is 
always  given  in  a  cereal  water  diluent  in  order  to  increase  its  nutritive 
value,  and  pure  cod-liver  oil  furnished  by  the  dispensary  is  given 
eight  months  in  the  year  to  increase  the  daily  amount  of  fat.  This, 
of  course,  is  anything  but  an  ideal  means  of  infant-feeding.  Many 
children  thrive  on  it,  however,  but  they  almost  invariably  show  some 
signs  of  malnutrition,  and  offer  less  resistance  to  illness  of  every 
nature.  In  spite  of  these  drawbacks  it  is  the  best  food  for  a  con- 
siderable number  of  children  during  the  summer  months  under 
existing  conditions  in  New  York  city. 

Adapted  Milk. — In  adapting  milk  for  infant-feeding  the  milk 
is  not  only  "modified"  (page  8i),  by  which  process  the  nutritional 
elements  are  changed  in  their  proportions  so  as  to  make  them  con- 
form as  nearly  as  possible  to  mother's  milk,  but  more  is  required 
— the  food  must  be  adapted  to  the  child's  digestive  capacity. 

If  the  modification  of  milk,  as  we  understand  it,  constituted  all 
that  was  required  in  infant-feeding,  the  artificial  feeding  of  infants 
would  be  a  comparatively  simple  matter.  Some  infants  will  take  read- 
ilv  anv  reasonable  modification  which  by  experience  has  been  found 
suitable  for  children  of  their  age.  In  others,  which  includes  the 
majority,  the  child  fed  on  cow's  milk  has  to  be  fed  according  to  his 
digestive  capabilities.  Every  feeding  case  must  be  studied  from 
its  own  individual  standpoint.  How  best  to  nourish  the  individual 
patient  can  be  learned  only  by  a  study  of  the  patient  himself.  No 
process  of  manipulation  by  the  addition  of  chemicals  or  gruels  can 
convert  cow's  milk  into  human  milk.  There  are  various  means 
available,  however,  sufficient  to  overcome  the  existing  differences, 
thereby  making  cow's  milk  a  suitable  food  even  for  those  who  at 
first  show  signs  of  marked  intolerance  of  it.  The  strength  and 
the  feeding  intervals  required  for  the  different  ages  in  average  well 
children  are  found  in  the  chapters  on  Modified  Milk,  page  8i. 

Symptomatic  Adaptation. — If  the  child  is  getting  a  suitable  food 
strength  at  proper  intervals  and  the  food  causes  illness,  the  difficulty 
may  rest  either  with  the  food  as  a  whole,  it  being  beyond  his  digestive 
capacity,  or  there  may  be  an  incapacity  for  one  or  more  of  its  nutri- 
tional elements.  If  the  food  as  a  whole  is  too  strong,  there  is  very  apt 
to  be  vomiting,  which  may  become  habitual,  or  there  may  be  colic  or 
constipation  or  diarrhea.  If  the  food  as  a  whole  is  too  w^eak,  it  will 
be  evidenced  by  hunger,  a  failure  to  gain  in  weight,  and  usually  by  con- 
stipation. If  sugar  is  given  in  excess — a  comparatively  rare  cause  of 
trouble,  if  not  more  than  7  percent  of  milk-sugar  is  given — it  will  be  in- 


SUBSTITUTE    breast-feeding;    ARTIFICIAL    FEEDING  95 

dicated  by  the  regurgitation  of  sour,  watery  material.  A  sour  odor  to 
the  patient's  breath  and  to  his  clothing  indicates  sugar  excess.  There 
may  not  be  pronounced  vomiting  in  such  a  case,  but  the  repeated 
regurgitation  when  the  patient  is  awake  is  sufficient  to  deprive  him 
of  a  goodly  amount  of  his  daily  food,  or  the  digestion  of  both  fat 
and  proteid  may  be  markedly  interfered  with,  and  the  whole  digestion 
deranged  as  a  result  of  what  was  primarily  a  sugar  incapacity  or 
sugar  excess.  When  sugar  is  at  fault,  the  indigestion  may  readily 
be  corrected  by  washing  out  the  stomach  for  a  few  days  (page  180) 
and  by  reducing  the  sugar  content  of  the  food  one-half.  Later, 
after  the  condition  is  relieved,  the  sugar  may  gradually  be  increased 
to  the  normal  percentage  of  seven.  A  child  may  be  getting  but  a 
2  percent  cow's-milk-fat  mixture  and  yet  suffer  from  fat  indigestion. 
Excessive  fat  or  fat  incapacity  also  gives  rise  to  vomiting  and  re- 
gurgitation in  which  particles  of  fat  may  often  be  seen.  Fat  may 
cause  also  frequent  green  undigested  stools,  the  passage  of  which  is 
associated  with  marked  tenesmus.  Fat-diarrhea  is  often  the  out- 
come of  fat-indigestion.  Cow's-milk  fat  was  not  intended  for  babies, 
and  when  it  disagrees  we  cannot  change  its  character — our  only 
method  of  adaptation  is  to  reduce  the  amount  given,  the  same  as 
with  the  sugar. 

The  casein  in  cow's  milk  is  its  important  nutritional  factor,  and 
in  adapting  cow's  milk  to  a  child's  digestive  capacity  it  is  oftentimes 
a  most  difhcult  factor  to  deal  with.  Temporarily  it  may  be  reduced 
with  safety  to  a  percentage  considerably  below  that  of  cow's  milk — 
to  0.25  percent,  for  instance — but  it  must  be  remembered  that  the 
patient  cannot  thrive  or  even  long  exist  without  this  proteid 
element  in  the  diet,  so  that  a  reduction  will  always  be  followed 
by  malnutrition.  It  is  necessary,  then,  to  give  proteid,  and  suc- 
cessful infant-feeding  means  that  we  must  change  it  through  adap- 
tation to  the  child's  digestive  capacity,  and  this,  fortunately,  is  often- 
times possible. 

The  Use  of  Alkalies  and  Antacids. — The  casein  of  human  milk 
when  it  enters  the  infant's  stomach  divides  into  small  flocculent 
masses.  Cow's  milk  entering  the  infant's  stomach,  without  an 
addition  of  an  alkali  or  other  influencing  medium,  is  precipitated 
by  the  pepsin  in  the  stomach  and  forms  a  heavy  curd,  which  consists 
of  paracasein,  at  which  the  child's  stomach  oftentimes  rebels,  as  it 
fails  of  digestion  or  assimilation.  The  adaptation  of  the  casein  of 
cow's  milk  to  the  child's  digestive  capacity  so  as  to  maintain  suitable 
nutrition,  is  a  central  point  around  which  the  whole  subject  of  infant- 
feeding  revolves.  It  will  be  noted  in  the  formulas  for  cow's-milk 
feeding  for  different  ages  that  lime-water  is  used  as  a  diluent. 
This  is  used  not  simply  as  a  diluent  of  cow's  milk  nor  to  render  the 
milk  alkaline,  as  has  frequently  been  stated ;  it  is  used  to  prevent  the 
coagulation  of  the  casein  and  the  resulting  formation  of  tough  curds 


96  NUTRITION    AND   GROWTH 

of  paracasein.  Simple  dilution  with  water  may  make  a  smaller 
curd,  but  it  does  not  produce  the  peculiar  flocculent  character 
peculiar  to  human  milk  that  follows  the  addition  of  alkalies  and 
antacids  to  cow's  milk.  In  the  presence  of  an  alkali  the  casein  does 
not  combine  with  the  acid  in  the  stomach,  consequently  the  resulting 
acid  coagulation  does  not  take  place,  hence  alkalies  and  antacids  are 
added  to  cow's  milk. 

Recently,  Poynton,  of  London,  advocated  the  use  of  citrate  of 
soda  with  a  view  of  preventing  the  solid  coagulation  of  the  casein. 
It  is  claimed  that  by  using  citrate  of  soda,  one  grain  to  the  ounce, 
sodium  paracasein  is  produced,  which  is  a  fluid.  Citric  acid  is 
liberated  and  unites  with  the  calcium,  forming  the  citrate  of  calcium, 
which  is  absorbed. 

Signs  of  indigestion  of  the  casein  in  the  milk  are  usually  pain 
and  discomfort.  There  are  usually  acute  attacks  of  colic.  There 
may  be  constipation  or  diarrhea  alternating  with  constipation, 
associated  with  the  passage  of  many  hard  curds  in  the  stools,  the 
patient  losing  steadily  in  weight.  In  such  instances  the  best  means 
of  adaptation  consists  in  reducing  the  amount  of  proteid  to  a  total 
of  I  percent  by  dilution  wnth  water,  and  the  addition  of  sufficient 
alkalies,  such  as  lime-water,  bicarbonate  of  soda,  or  citrate  of  soda, 
to  form  a  curd  more  readily  attacked  by  the  digestive  juices. 

Whey-feeding. — Whey  mixtures  may  be  of  temporary  use  in  these 
cases.  In  whev  the  casein  is  largely  removed — about  0.3  percent 
remaining.     Analyses  of  whey  show  a  nutritional  equivalent  of  about : 

0.5  percent  fat; 
0.9  percent  lactalbumin; 
0.3  percent  casein; 
4.5  percent  sugar. 

As  whey  is  ordinarily  made,  it  is  impossible  to  obtain  a  lower  per- 
centage of  casein  than  0.25.  The  amount  of  casein  will  often- 
times reach  0.5  percent  unless  it  is  heated  and  strained  a  second 
time.  The  deficiency  in  fat  may  be  overcome  by  adding  gravity 
cream  (page  107)  of  the  same  age  as  the  milk  from  which  the  whey 
is  obtained,  in  the  proportion  of  one  or  two  ounces  to  a  pint 
of  whey.  This,  of  course,  carries  with  it  a  very  small  amount  of 
casein,  which  may  make  a  total  beyond  the  child's  digestive  capac- 
ity. Low  proteid  must  be  given  onlv  during  acute  illness  or  in  those 
digestively  ill,  and  should  be  a  diet  for  temporary  purposes  until 
the  child  is  able  to  care  for  a  more  suitable  nourishment.  My  best 
results  with  the  whey-proteid  feeding  have  been  in  my  laboratory 
cases.  During  the  past  winter  I  fed  nineteen  infants  in  this  way  on 
the  Walker-Gordon  milk,  the  casein  being  given  at  a  minimum  at 
first — 0.3  percent  with  0.9  percent  lactalbumin.  Later  it  was  gradu- 
ally increased  as  the  child  showed  that  he  could  assimilate  it. 


SUBSTITUTE  breast-feeding;  artificial  feeding  97 

Adaptation  by  the  Use  of  Cereal  Gruels.— It  is  claimed  by  many 
excellent  observers  that  the  use  of  cereal  gruels  causes  a  mechanical 
division  of  the  casein,  and  it  is  thus  more  readily  acted  upon  by 
the  digestive  juices.  While  I  use  gruels  as  milk  diluents  largely, 
and  frequently  as  milk  substitutes,  I  have  yet  to  be  convinced  that 
in  difficult  feeding  cases  they  possess  any  great  value  in  the  adapta- 
tion of  casein  to  the  child's  digestive  capacity.  They  are  valuable 
adjuncts  to  the  diet  in  cases  in  which  weak-milk  foods  must  be  given, 
but  I  do  not  recall  a  case,  nor  can  I  find  one  among  my  records, 
where  I  thought  the  use  of  a  stronger  casein  possible  because  of  the 
cereal  water  diluent.  Repeated  trials  with  gruels,  in  delicate  or  in 
marasmic  infants,  who  afford  the  crucial  tests  in  any  milk  adaptation, 
have  never  enabled  me  to  give  a  stronger  milk  proteid  because  of 
their  presence.  Having  fed  gruels  as  diluents  in  a  large  number 
of  cases  for  years,  I  have  had  abundant  opportunity  to  see  enormous 
curds  vomited  and  passed  by  the  rectum  by  children  on  a  milk  and 
gruel  diet  in  spite  of  test-tube  demonstrations  of  the  minute  division 
of  the  curd  when  the  milk  was  treated  with  gruels.  The  advantage 
of  a  cereal  diluent  lies  in  the  fact  that  a  greater  amount  of  food  is 
given,  both  types  of  enzyme  being  made  use  of. 

Adaptation  through  Peptonization. — When  a  child  has  a  casein 
incapacity  to  such  a  degree  that  he  is  not  able  to  take  cow's  milk 
when  properly  diluted  and  given  at  suitable  intervals,  the  peptoniza- 
tion of  milk  (page  115)  may  aid  us,  although  I  have  frequently  been 
sorely  disappointed  in  its  use.  Theoretically,  peptonization — the 
predigestion  of  the  food — should  be  a  solution  of  many  digestive 
problems.  Its  efficiency  in  actual  use  can  be  learned  from  mortality 
statistics  of  children  under  two  years  of  age  in  large  cities,  an  immense 
proportion  of  the  deaths  being  due  to  nutritional  errors  either  primar- 
ily or  secondarily.  Not  every  infant,  of  course,  is  given  peptonized 
milk;  but  if  it  possessed  the  value  claimed  for  it  by  some  of  its 
advocates,  the  demand  would  be  such  as  to  compel  its  universal 
use  and  difficult  feeding  cases  would  be  no  more. 

Perhaps  I  treat  five  or  six  cases  of  casein  indigestion  a  year  in 
which  peptonization  is  unquestionably  valuable.  In  using  pep- 
tonized milk  the  proteid  strength  should  be  reduced  to  i  percent — 
the  lowest  point  compatible  with  safety.  The  amount  and  intervals 
of  feeding  should  correspond  with  those  suggested  for  the  age  of 
the  patient.  I  have  found  the  following  method  the  best:  Fifteen 
minutes  before  nursing  the  bottle  is  rem.oved  from  the  ice  and  from 
one-eighth  to  one-fourth  of  a  tube  (Fairchild's  peptonizing  tube), 
depending  upon  the  amount  of  milk  in  the  bottle,  is  added.  The 
bottle  is  then  placed  in  water  sufficiently  heated,  110°  to  120°  F., 
to  make  it  the  right  temperature  for  a  child  at  the  end  of  ten  minutes. 
The  degree  of  the  temperature  of  the  water  must  of  necessity  vary 
7 


98  NUTRITION    AND   GROWTH 

according  to  the  temperature  in  the  bottle  and  the  amount  to  be 
heated. 

Malt-soup  Feeding. — Recently  several  cases  of  malnutrition  due 
to  difficult  feeding  have  been  under  my  observation  in  whom  "malt 
soup"  furnished  a  satisfactory  diet  when  every  other  means  had 
failed.  The  cases  were  those  in  which  the  child  was  of  slow  growth 
due  to  faulty  assimilation  without  the  presence  of  vomiting  or 
diarrhea. 

The  malt  soup  is  prepared  from  "Loeflund's  Malt  Soup-extract," 
a  preparation  of  malt  and  potassium  carbonate — Keller's  formula. 
The  directions  for  the  preparation  of  the  food  are  as  follows : 

"  Three  and  one-half  ounces  of  Malt  Soup-extract  are  added  to  one 
pint  of  warm  water  and  dissolved.  This  is  solution  No.  i.  Then 
suspend  or  mix  three  ounces  by  measure  or  two  ounces  by  weight 
of  wheat  flour  in  one  pint  of  milk.  When  the  wheat  flour  and  milk 
solution  is  strained  it  is  added  to  the  Malt  Soup-extract  solution 
and  slowly  brought  to  a  boil,  being  stirred  constantly  over  a  slow  Are. 

"For  young  and  weak  children  dilute  the  Malt  Soup  with  one- 
third  part  water." 

In  not  a  few  instances  I  found  it  necessary  to  give  the  malt  soup 
with  equal  parts  of  water  at  the  beginning  of  its  use. 

COWS  MILK 
As  cow's  milk  furnishes  the  most  available  basis  of  nutrition  for 
the  infant  who  is  to  be  deprived  of  the  mother's  milk,  it  is  necessary, 
in  order  to  secure  the  best  results  in  its  use  as  an  infant  food,  that 
it  contain  total  solids  between  12  and  13  percent,  and  that  the  solids 
be  represented  in  the  nutritional  elements  in  somewhat  the  following 
proportions : 

Fat 3.5       to  4      percent 

Sugar 4  to  4.5         " 

Total  proteid. 3  to  4  " 

Ash 0.7      to  0.9 

Specific  gravity 1.028  to  1.033 

In  order  that  there  may  be  a  fairly  constant  strength  of  the  milk,, 
herd-milk  is  to  be  preferred  to  the  product  of  one  or  two  cows,  as 
the  quality  of  the  latter  may  vary  considerably  from  day  to  day. 
It  has  been  demonstrated  that  the  best  cows  for  this  purpose  are 
what  is  known  as  "grade  cows,"  that  is,  not  pure  bred.  Such  cows 
thrive  better,  are  more  easily  kept  healthy,  and  are  more  uniform  in 
the  nutritional  equivalent  of  their  milk-supply  than  are  high-class 
registered  herds  of  the  Alderney  or  Jersey  strain. 

The  fat  of  cow's  milk  is  in  the  form  of  a  fine  emulsion  and  sepa- 
rates as  cream.  Its  character  is  affected  by  the  cow's  food,  being 
softened  when  some  articles  are  fed  and  hardened  when  other  kinds 
of  food  are  used. 


cow  S    MILK 


99 


There  are  several  proteids  of  cow's  milk,  of  which  the  most 
important  and  best  known  are  casein,  which  forms  the  curd,  and 
lactalbumin,  the  proportion  being  about  three  parts  casein  to  one 
part  of  lactalbumin.  In  mixed  milk  from  several  cows  this  propor- 
tion is  by  no  means  constant.  The  sugar  of  cow's  milk  is  lactose, 
which  is  less  sweet  to  the  taste  than  cane-sugar  or  granulated  sugar 
or  maltose  derived  from  starch.  That  cow's  milk  shall  contain  a 
certain  quantity  of  total  solids,  and  that  it  shall  be  of  a  specific 
gravity  within  certain  limits,  is  necessary  in  order  that  it  may 
supply  nourishment  to  the  child.  Another  most  important  feature 
to  be  taken  into  consideration  is  cleanliness,  which  naturally  brings 
us  to  a  consideration  of  the  bacteriology  of  milk — a  large  subject 
which  can  be  but  briefly  referred  to  here.  Milk  fresh  from  the 
udder  contains  very  few  bacteria,  particularly  if  the  first  two  or 
three  jets  from  each  teat  are  discarded.  The  time  for  bacterial  con- 
tamination is  during  the  milking  and  while  the  milk  remains  in  the 
stable.  Certain  forms  of  bacteria  are  harmless,  and  it  is  impossible 
to  have  a  milk  absolutely  free  from  bacteria.  What  we  need  to 
know  is  how  dangerous  bacteria  get  into  the  milk,  and  how  they 
cause  changes  that  may  convert  it  into  a  poison  of  greater  or  less 
virulence. 

Harmless  Bacteria. — The  souring  of  milk  is  the  result  of  the 
presence  of  bacteria  which  produce  changes  in  the  sugar  of  milk 
with  the  formation  of  lactic  acid.  The  "turning"  of  milk  during  a 
thunder- shower  is  due  to  certain  changes  in  the  atmosphere  that 
aid  in  the  development  of  the  bacteria  which  convert  lactose  into 
lactic  acid. 

Harmful  Bacteria. — Bacteria  of  decomposition  under  conditions 
favorable  to  their  growth  attack  the  proteid  constituents  of  the 
milk,  producing  putrefactive  changes  with  evolution  of  poisons 
which  may  be  of  the  greatest  virulence.  The  putrefactive  bacteria 
are  always  present  in  stables  where  manure  is  allowed  to  collect,  and 
where  cleanliness  is  not  observed.  When  we  remember  what  a 
culture-field  milk  affords  to  bacteria,  and  when  we  see  the  manner 
and  the  surroundings  in  which  it  is  usually  drawn,  it  is  not  sur- 
prising that  it  should  contain  many  millions  of  bacteria  to  a  cubic 
centimeter.  They  may  enter  the  milk  from  the  dust  in  the  stable — 
a  very  fruitful  source — or  they  may  find  entrance  from  the  milker's 
hands  or  from  droppings  of  fine  particles  of  manure  from  the  belly 
of  the  cow.  These  are  among  the  most  dangerous  forms  of  bacteria 
found  in  milk.  When  bacteria  once  gain  entrance  into  the  milk, 
their  growth  is  most  rapid.  In  corroboration  of  this,  the  observa- 
tion of  Parsons*  is  most  interesting  and  instructive.  He  writes  as 
follows : 

"There  is  more  or  less  dust  floating  in  the  air  of  houses  and 
'  Cornell  Reading  Course,  December,  1905. 


lOO  NUTRITION    AND   GROWTH 

stables,  and  this  dust  is  constantly  settling.  When  it  falls  into 
milk,  it  carries  bacteria  with  it.  If  the  milk  is  warm,  these  bacteria 
multiply  very  rapidly;  if  the  milk  is  cold,  they  may  develop  slowly, 
but  they  will  be  ready  for  rapid  growth  as  soon  as  the  temperature  is 
raised.  The  production  and  care  of  good  milk  depend  very  much 
on  the  care  taken  to  prevent  dust  from  getting  into  it,  and  the 
maintaining  of  a  low  temperature  after  it  is  drawn. 

"Last  summer,  Walter  E.  King,  of  the  State  Veterinary  College, 
and  myself  [Parsons],  made  a  number  of  tests  to  determine  the 
importance  of  different  sources  of  milk  contamination.  In  most  of 
these  tests  a  definite  quantity  of  sterilized  milk  at  98°  F.  was  exposed 
to  some  one  kind  of  contamination  that  we  wished  to  test.  The 
milk  was  then  examined,  and  in  that  way  we  could  obtain  a  fairly 
accurate  idea  of  the  extent  of  this  particular  kind  of  contamination. 
Some  of  the  experiments  and  their  results  are  as  follows : 

"  I.  Exposure  to  Air  in  the  Stable:  Two  liters  (about  two  quarts) 
of  sterilized  milk  were  placed  in  a  sterile  pail  and  exposed  seven 
minutes  to  the  stable  air  in  a  passageway  behind  the  cows.  This 
stable  was  doubtless  cleaner  than  the  average,  and  the  air  contained 
less  dust  than  is  often  found  in  places  where  milk  is  being  handled. 
Immediately  after  this  exposure,  the  milk  was  'planted,'  and  we 
found  it  to  contain  2800  bacteria  per  cubic  centimeter  (about  fifteen 
drops) ;  in  other  words,  between  5,000,000  and  6,000,000  bacteria 
had  fallen  into  the  two  liters  of  milk  in  this  short  time. 

"2.  Pouring  of  Milk:  When  milk  is  poured  from  one  vessel 
into  another,  a  very  large  surface  is  exposed  to  the  air,  and  great 
numbers  of  bacteria  are  swallowed  up.  The  following  tests  illus- 
trate this  point :  About  five  liters  of  milk  were  poured  from  one  can 
to  another  eight  times  in  the  stable  air.  It  was  found,  after  pouring, 
that  this  milk  contained  practically  100  bacteria  per  cubic  centi- 
meter more  than  it  contained  before  pouring ;  in  other  words,  about 
600,000  bacteria  had  gotten  into  the  milk  on  account  of  this  ex- 
posure. 

"In  another  similar  experiment,  when  there  was  a  little  more 
dust  in  the  air,  the  contamination  due  to  pouring  eight  times  was 
two  and  one-half  times  greater  than  in  the  preceding  experiment. 

"3.  Contaminated  Utensils:  Much  contamination  of  milk  results 
from  putting  it  into  dishes  that  have  been  cleaned  and  then  exposed 
where  dust  can  fall  into  them.  In  experiments  to  determine  what 
this  kind  of  contamination  amounts  to,  it  has  been  found  that  when 
little  care  is  taken  to  protect  the  dishes,  the  milk  will  often  contain 
several  hundred  times  as  many  bacteria  as  when  the  utensils  were 
protected  from  dust.  In  order  to  illustrate  this  point,  two  pails 
were  carefully  washed  and  sterilized.  One  of  them  was  covered 
with  sterile  cloth  to  keep  dust  from  falling  into  it.  The  other  was 
left  exposed  for  only  a  few  minutes  to  the  air  of  a  clean  creamery. 


cow's   MILK 


A  small  quantity  of  sterile  milk  was  then  put  into  each  pail,  rinsed 
around,  and  then  examined  for  bacteria.  It  was  found  that  the 
milk  in  the  pail  which  was  not  protected  from  dust  contained  1600 
more  bacteria  per  cubic  centimeter  than  the  milk  in  the  protected 
pail. 

"4.  Contamination  from  the  Cow's  Udder  and  Body:  Great  num- 
bers of  bacteria  fall  into  the  milk  when  it  is  being  drawn,  because 
the  milking-pail  is  directly  under  the  udder,  which  is  being  shaken 
more  or  less  by  the  milker.  This  kind  of  contamination  may  be 
reduced  by  cleaning  the  udder.  For  example,  it  was  found  that 
sterile  milk,  exposed  under  the  udder  as  long  as  it  takes  to  milk  a 
cow,  while  the  udder  was  being  shaken  about  the  same  as  when 
milk  is  being  drawn,  contained  19,000  bacteria  per  cubic  centimeter. 


M- 


Fig.  12. 


Figs.  12,  13.— Milk  Pails. 


Fig-  13- 


In  this  case  the  udder  had  been  wiped  off  with  a  dry  cloth  in  much  the 
same  way  as  is  done  in  fairly  good  dairies. 

"  In  a  similar  test  the  udder  was  wiped  with  a  damp  cloth,  when 
the  number  of  bacteria  was  reduced  to  4500  per  cubic  centimeter. 
In  a  third  experiment  the  udder  was  wiped  with  a  cloth  dampened 
in  a  4  percent  carbolic  acid  solution,  when  the  number  of  bacteria 
was  found  to  be  3200  per  cubic  centimeter.  In  cases  where  no 
particular  care  is  taken  to  clean  the  udder,  the  bacteria  getting  into 
the  milk  from  this  source  may  run  up  into  the  millions. 

"5.  Importance  of  Small  Openings  in  Milk  Pails:  (See  Fig.  12.) 
From  the  experiments  above  mentioned,  it  will  be  seen  that  it  is 
impracticable  to  clean  the  udder  or  free  the  air  from  dust  so  per- 
fectly that  no  bacteria  will  fall  into  the  milk.     The  next  question  is. 


I02  NUTRITION    AND   GROWTH 

How  can  we  reduce  the  number  of  those  that  will  fall  in,  despite  all 
reasonable  precautions?  The  easiest  way  known  is  to  use  a  small- 
top  milking-pail,  thus  reducing  the  size  of  the  opening  through 
which  dirt  can  fall  in.  An  experiment  to  illustrate  this  point 
showed  that  milk  drawn  into  an  ordinary  milking-pail  contained 
1300  bacteria  per  cubic  centimeter;  while  that  drawn  into  a  pail 
with  an  opening  about  one-half  as  wide,  contained  only  320  bacteria 
per  cubic  centimeter.  This  is  exactly  proportionate  to  the  number 
of  square  inches  of  exposed  surface  in  the  two  pails.  For  example, 
a  pail  having  a  circular  top  fourteen  inches  in  diameter  has  an 
opening  of  153.86  square  inches;  a  pail  with  a  twelve-inch  top  has  an 
opening  of  11 3.04  square  inches ;  one  with  a  ten-inch  top  has  an  open- 
ing of  79.79  square  inches;  and  a  pail  with  an  opening  six  inches  in 
diameter  has  an  exposure  of  28.26  square  inches.      (See  Fig.  13.) 

"  Milkers  should  get  into  the  habit  of  using  the  small-top  pail, 
as  it  is  one  of  the  easiest  of  all  ways  of  reducing  the  number  of  bac- 
teria that  fall  into  the  milk. 

"  6.  Contamination  by  Flies:  A  fly  or  a  bit  of  hay  or  straw  or  a 
piece  of  sawdust  or  a  small  hair  may  carry  enormous  numbers  of 
bacteria  into  milk,  as  is  shown  by  the  following  experiments: 

"A  living  fly  was  introduced  into  500  c.c.  of  sterile  milk.  The 
milk  was  shaken  one  minute,  when  it  was  found  to  contain  42  bac- 
teria per  cubic  centimeter.  After  twenty-four  hours  at  room- 
temperature,  it  contained  765,000  bacteria  per  cubic  centimeter, 
and  after  twenty-six  hours,  5,675,000. 

"7.  Dirt  in  the  Milk:  A  piece  of  hay  about  two  inches  long  was 
placed  in  500  c.c.  of  sterile  milk.  The  milk  was  shaken  one  minute, 
when  it  contained  3025  bacteria  per  cubic  centimeter.  After 
twenty-four  hours  at  room-temperature,  it  contained  3,412,500 
bacteria  per  cubic  centimeter. 

"  One  piece  of  sawdust  from  the  stable  floor  was  put  into  500  c.c. 
of  sterile  milk.  The  milk  was  shaken  one  minute  and  its  bacterial 
content  was  then  found  to  be  4080  per  cubic  centimeter.  After 
twenty-four  hours  at  room-temperature  it  was  7,000,000  per  cubic 
centimeter. 

"A  hair  from  a  cow's  flank  was  put  into  500  c.c.  of  sterile  milk. 
After  shaking  the  milk  for  one  minute  it  contained  52  bacteria  per 
cubic  centimeter.  After  twenty-four  hours  at  room-temperature  it 
contained  55,000  per  cubic  centimeter,  and  after  thirty-six  hours, 
over  5,000,000  bacteria  per  cubic  centimeter." 

The  results  of  the  foregoing  observations  are  given  in  detail, 
in  order  to  impress  upon  the  reader  the  necessity  of  exerting  his 
energies  to  the  end  that  the  infants  under  his  care  may  receive  a 
less  contaminated  milk-supply. 

Market  Milk. — The  legal  standards  for  pure  milk  in  most  instances 
relate  only  to  the  chemical  composition  of  the  milk.     The  laws  of 


cow  S    MILK  103 

most  of  the  States  call  for  12  percent  of  total  solids,  and  at  least  3 
percent  of  fat.  If  the  milk  contains  less  than  these  percentages  it  is 
considered  impure,  even  if  it  is  just  as  it  was  when  it  left  the  cow's 
udder.  Some  cows  give  milk  considerably  below  this  standard. 
The  chemical  analysis  of  milk  does  not  show  whether  it  is  suitable 
for  use  as  an  infant  food,  this  point  being  decided  according  to  its 
freshness  and  the  care  with  which  it  has  been  handled  with  reference 
to  the  exclusion  of  bacteria  and  the  prevention  of  their  growth. 

The  production  of  clean,  safe  milk  is  expensive.  It  costs  at 
least  two  cents  a  quart  to  produce  milk,  without  allowing  anything 
for  the  labor  of  caring  for  the  cows.  The  milk  must  be  carried  to 
the  consumer,  which  is  also  expensive.  Yet,  in  New  York  city,  milk 
that  possesses  the  legal  requirements  retails  in  the  grocery  stores, 
during  the  summer  months,  at  3^  cents  a  quart— two  quarts  for 
seven  cents.  This  milk  is  known  as  "grocery  milk,"  and  is  a  very 
poor  food  for  infants.  It  is  teeming  with  bacteria,  as  little  care  is 
taken  in  its  production. 

The  next  grade  of  milk  is  sold  in  quart  bottles  which  have  been 
filled  in  the  country,  packed  in  cracked  ice,  and  shipped  to  the  city. 
The  milk  contains  many  bacteria,  but  is  far  better  than  grocery 
milk.     It  is  retailed  to  the  consumer  for  about  eight  cents  a  quart. 

Certified  Milk.— The  best  grade  of  milk,  and  the  one  which 
should  be  used  in  feeding  infants  whenever  possible,  is  known 
as  "certified  milk,"  and  is  produced  under  the  direction  of  what 
is  known  as  a  "milk  commission."  The  estabhshing  of  "m_ilk 
commissions"  in  different  cities  throughout  the  country  has  been 
the  means  of  securing  a  much  better  milk-supply  than  was  form- 
erly possible,  and  has  doubtless  been  instrumental  in  saving  many 
lives.  To  Dr.  H.  L.  Coit,  of  Newark,  N.  J.,  is  due  the  credit  of 
organizing  the  first  milk  commission.  Certified  milk  must  conform 
to  certain  standards  as  to  its  nutritional  value,  and  as  to  the  num- 
ber of  bacteria  per  cubic  centimeter.  These  standards  are  estab- 
lished by  a  committee  of  medical  men  who  compose  the  milk  com- 
mission and  who  have  complete  control  of  the  dairy  and  its  entire 
output. 

The  Milk  Commission  of  the  New  York  County  Medical  Society 
required  a  standard  of  milk  not  exceeding  30,000  bacteria  in  a  cubic 
centimeter.  When  a  dairyman  has  shown  to  the  satisfaction  of  the 
Commission  that  he  can  produce  a  milk  up  to  the  required  standard, 
he  is  allowed  to  attach  to  his  bottles  of  milk  labels  furnished  by  the 
Commission  certifying  to  that  fact.  Milk  thus  "certified"  is  taken 
from  the  delivery  wagons  from  time  to  time  and  subjected  to  exami- 
nation by  their  bacteriologist  in  order  to  determine  w^hether  it 
conforms  to  the  requirements  of  the  Commission.  In  order  to  show 
the  care  and  supervision  necessary  for  the  production  of  certified 
milk,  the  requirements  of  the  Milk  Commission  of  the  New  York 


I04  NUTRITION    AND   GROWTH 

County  Medical  Society  for  the  Production  of  "certified  milk"  are 
given  in  full :  ^ 

"The  most  practicable  standard  for  the  estimation  of  cleanliness 
in  the  handling  and  care  of  milk  is  its  relative  freedom  from  bacteria. 
The  Commission  has  tentatively  fixed  upon  a  maximum  of  30,000 
germs  of  all  kinds  per  cubic  centimeter  of  milk,  which  must  not  be 
exceeded  in  order  to  obtain  the  indorsement  of  the  Commission. 
This  standard  must  be  attained  solely  by  measures  directed  toward 
scrupulous  cleanliness,  proper  cooling,  and  prompt  delivery.  The 
milk  certified  by  the  Commission  must  contain  not  less  than  4  percent 
of  butter  fat  on  the  average,  and  must  possess  all  the  other  charac- 
teristics of  pure,  wholesome  milk. 

"In  order  that  dealers  who  incur  the  expense  and  take  the  pre- 
cautions necessary  to  furnish  a  truly  clean  and  wholesome  milk  may 
have  some  suitable  means  of  bringing  these  facts  before  the  public, 
the  Commission  offers  them  the  right  to  use  caps  on  their  milk  jars 
stamped  with  the  words :  'Certified  by  the  New  York  County  Medical 
Society  Milk  Commission.' 

"Rules  for  the  Producer. — i.  Tlie  Barnyard. — The  barnyard 
should  be  free  from  manure  and  well  drained,  so  that  it  may  not 
harbor  stagnant  water.  The  manure  which  collects  each  day  should 
not  be  piled  close  to  the  barn,  but  should  be  taken  several  hundred 
feet  away.  If  these  rules  are  observed  not  only  will  the  barnyard 
be  free  from  objectionable  smell,  which  is  always  an  injury  to  the 
milk,  but  the  number  of  flies  in  summer  will  be  considerably  dimin- 
ished. These  flies,  in  themselves,  are  an  element  of  danger;  for  they 
are  fond  of  both  filth  and  milk,  and  are  liable  to  get  into  the  milk 
after  having  soiled  their  bodies  and  legs  in  recently  visited  filth, 
thus  carrying  it  into  the  milk.  Flies  also  irritate  cows,  and  by 
making  them  nerv^ous  reduce  the  amount  of  their  milk. 

"2.  The  Stable. — In  the  stable  the  principles  of  cleanliness  must 
be  strictly  observed.  The  room  in  which  the  cows  are  milked  should 
have  no  storage  loft  above  it;  where  this  is  not  feasible,  the  floor  of 
the  loft  should  be  tight,  to  prevent  the  sifting  of  dust  into  the  stable 
beneath.  The  stable  should  be  well  ventilated,  lighted,  and  drained, 
and  should  have  tight  floors,  preferably  of  cement.  They  should 
be  whitewashed  inside  at  least  twice  a  year,  and  the  air  should  always 
be  fresh  and  without  bad  odor.  A  sufficient  number  of  lanterns 
should  be  provided  to  enable  the  necessary  work  properly  to  be  done 
during  dark  hours.  There  should  be  an  adequate  water-supply 
and  the  necessary  wash-basins,  soap,  and  towels.  The  manure 
should  be  removed  from  the  stalls  twice  dailv,  except  when  the 
cows  are  outside  in  the  fields  the  entire  time  between  the  morning  and 
afternoon  milkings.  The  manure  gutter  must  be  kept  in  a  sanitary 
condition,  and  all  sweeping  and  cleaning  must  be  finished  at  least 
^Chapin:  "Infant  Feeding." 


cow's    MILK  lO- 

twenty  minutes  before  milking,  so  that  at  that  time  the  air  may  be 
free  from  dust. 

"3.  Water-supply. — The  whole  premises  used  for  dairy  purposes,, 
as  well  as  the  barn,  must  have  a  supply  of  water  absolutely  free  frorn 
any  danger  of  pollution  with  animal  matter,  sufficiently  abundant 
for  all  purposes,  and  easy  of  access. 

"4.  The  Cows. — The  cows  should  be  examined  at  least  twice  a 
year  by  a  skilled  veterinarian.  Any  animal  suspected  of  being  in 
bad  health  must  be  promptly  removed  from  the  herd  and  her  milk 
rejected.  Never  add  an  animal  to  the  herd  until  it  has  been  tested 
for  tuberculosis  and  it  is  certain  that  it  is  free  from  disease.  Do  not 
allow  the  cows  to  be  excited  by  hard  driving,  abuse,  loud  talking, 
or  any  unnecessary  disturbance.  Do  not  allow  any  strongly  flavored 
food,  like  garlic,  which  will  affect  the  flavor  of  the  milk,  to  be  eaten 
by  the  cows. 

"Groom  the  entire  body  of  the  cow  daily.  Before  each  milking 
wipe  the  udder  with  a  clean,  damp  cloth,  and,  when  necessar}^ 
wash  it  with  soap  and  clean  water  and  wipe  it  dry  with  a  clean  towel. 
Never  leave  the  udder  wet,  and  be  sure  that  the  water  and  towel 
used  are  clean.  If  the  hair  in  the  region  of  the  udder  is  long  and  not 
easily  kept  clean,  it  should  be  clipped.  The  cows  must  not  be 
allowed  to  lie  down,  after  being  cleaned  for  milking,  until  the  milking 
is  finished.  A  chain  or  rope  must  be  stretched  under  the  neck  to 
prevent  this. 

"All  milk  from  cows  sixty  days  before  and  ten  days  after  calving 
must  be  rejected. 

"5.  The  Milkers.— The  milker  should  be  personally  clean.  He 
should  neither  have  nor  come  in  contact  with  any  contagious  disease 
while  employed  in  milking  or  handling  milk.  In  case  of  any  such 
illness  in  the  person  or  family  of  any  employee  in  the  dairy,  such 
employee  must  absent  himself  from  the  dairy  until  a  physician 
certifies  that  it  is  safe  for  him  to  return. 

"Before  milking,  the  hands  should  be  thoroughly  washed  in 
warm  water  with  soap  and  a  nail-brush  and  well  dried  with  a 
clean  towel.  On  no  account  should  the  hands  be  wet  during  the 
milking. 

"  The  milking  should  be  done  regularly  at  the  same  hour  morning 
and  evening,  and  in  a  quiet,  thorough  manner.  Light-colored 
washable  outer  garments  should  be  worn  during  milking.  Thev 
should  be  clean  and  dry,  and  when  not  in  use  for  this  purpose  should 
be  kept  in  a  clean  place  protected  from  dust.  Milking-stools  must 
be  kept  clean.     Iron  stools,  painted  white,  are  recommended. 

"6.  Helpers  Other  than  Milkers. — All  persons  engaged  in  the 
stable  and  dairy  should  be  reliable  and  intelligent.  Children  under 
twelve  years  should  not  be  allowed  in  the  stable  during  milking, 
since  in  their  ignorance  they  may  do  harm,  and  from  their  liability 


Io6  NUTRITION    AND   GROWTH 

to  contagious  diseases  they  are  more  apt  than  older  persons  to 
transmit  them  through  the  milk. 

"  7.  Small  Animals. — Cats  and  dogs  must  be  excluded  from  the 
stable  during  the  time  of  milking. 

"8.  The  Milk. — The  first  few  streams  from  each  teat  should  be 
discarded,  in  order  to  free  the  milk-ducts  from  milk  that  has  re- 
mained in  them  for  some  time  and  in  which  bacteria  are  sure  to  have 
multiplied  greatly.  If,  in  any  milking,  a  part  of  the  milk  is  bloody 
or  stringy  or  unnatural  in  appearance,  the  whole  quantity  of  milk 
yielded  by  that  animal  must  be  rejected.  If  any  accident  occurs  by 
which  the  milk  in  a  pail  becomes  dirty,  do  not  try  to  remove  the 
dirt  by  straining,  but  reject  all  the  milk  and  cleanse  the  pail.  The 
milk-pails  used  should  have  an  opening  not  exceeding  eight  inches 
in  diameter. 

"Remove  the  milk  of  each  cow  from  the  stable,  immediately 
after  it  is  obtained,  to  a  clean  room,  and  strain  it  through  a  sterilized 
strainer. 

"The  rapid  cooling  of  milk  is  a  matter  of  great  importance. 
The  milk  should  be  cooled  to  45°  F.  within  one  hour.  Aeration  of 
pure  milk  beyond  that  obtained  in  milking  is  unnecessary. 

"All  dairy  utensils,  including  bottles,  must  be  thoroughly 
cleansed  and  sterilized.  This  can  be  done  by  first  thoroughly 
rinsing  in  warm  water,  then  washing  with  a  brush  and  soap  or  other 
alkaline  cleansing  material  and  hot  water,  and  thoroughly  rinsing. 
After  this  cleansing,  they  should  be  sterilized  with  boiling  water 
or  steam,  and  then  kept  inverted  in  a  place  free  from  dust. 

"9.  The  Dairy. — The  room  or  rooms  w^here  the  bottles,  milk- 
pails,  strainers,  and  other  utensils  are  cleaned  and  sterilized  should 
be  separated  somewhat  from  the  house,  or  when  this  is  impossible 
have  at  least  a  separate  entrance,  and  be  used  only  for  dairy  purposes, 
so  as  to  lessen  the  danger  of  transmitting  through  the  milk  contagious 
diseases  which  may  occur  in  the  home. 

"Bottles,  after  filling,  must  be  closed  with  sterilized  discs  and 
capped  so  as  to  keep  all  dirt  and  dust  from  the  inner  surface  of  the 
neck  and  mouth  of  the  bottle. 

"  10.  Examination  of  the  Milk  and  Dairy  Inspection. — In  order 
that  the  dealers  and  the  Commission  may  be  kept  informed  of  the 
character  of  the  milk,  specimens  taken  at  random  from  the  day's 
supply  must  be  sent  weekly  to  the  Research  Laboratory  of  the 
Health  Department,  where  examinations  will  be  made  by  experts 
for  the  Commission,  the  Health  Department  having  given  the  use 
of  its  laboratories  for  this  purpose. 

"The  Commission  reserves  to  itself  the  right  to  make  inspections 
of  certified  farms  at  any  time  and  to  take  specimens  of  milk  for 
examination.  It  also  reserv^es  the  right  to  change  its  standards  in 
any  reasonable  manner  upon  due  notice  being  given  the  dealers." 


CREAM  107 

Naturally,  milk  produced  in  this  way  is  more  expensive  than  when 
little  or  no  care  is  used,  more  help  is  required,  and  help  of  a  more 
expensive  type.  Certified  milk,  or  its  equivalent,  is  sold  in  New 
York  city  at  prices  ranging  from  twelve  to  eighteen  cents  a  quart. 

Examination  of  Cow's  Milk. — In  cow's  milk,  as  in  human  milk, 
a  chemical  analysis  is  necessary  in  order  to  know  accurately  the 
nutritional  elements.  The  specific  gravity  varies  from  i  .029  to  i  .035. 
Milk  is  acid  in  reaction  to  phenolphthalein,  and  may  be  neutral  to 
litmus.  The  Babcock  milk-test  machine  is  what  is  generally  em- 
ployed in  examining  cow's  milk  in  laboratories  and  institutions. 
The  test  consists  in  mixing  the  milk  with  strong  sulphuric  acid  which 
dissolves  the  proteids  and  liberates  the  fat,  the  quantity  of  which 
is  read  off  from  the  graduated  neck  of  the  bottle  used  in  mixing  the 
milk  and  acid.  Only  the  fat  is  determined  in  this  way.  Knowing 
the  fat  and  the  specific  gravity,  the  solids  other  than  fat  may  readily 
be  determined  by  adding  to  one-fourth  of  the  specific  gravity,  reading 
to  the  right  of  the  decimal  point,  one-fifth  of  the  percentage  of  fat. 

CREAM 

Market  creams  are  known  as  "gravity  cream"  and  "centrifugal 
cream." 

Gravity  Cream. — Gravity  cream  is  obtained  by  allowing  the  milk 
to  stand  for  a  certain  length  of  time  and  then  removing  the  cream. 
When  milk,  as  soon  as  it  is  drawn,  is  placed  in  a  quart  milk-bottle  or 
fruit- jar  and  kept  at  a  temperature  of  between  40°  and  50°  F.,  most  of 
the  fat  will  have  risen  at  the  end  of  five  hours.  When  the  cream  is 
carefully  removed  at  the  end  of  this  time,  from  0.3  to  0.8  percent  of 
fat  will  remain  in  the  milk.  The  fat  content  of  gravity  cream  is 
subject  to  considerable  variation,  depending,  of  course,  upon  the 
richness  of  the  milk  and  the  manner  in  which  it  is  treated,  particularly 
as  relates  to  rapid  cooling.  In  the  cream  from  well-kept  grade  cows 
the  fat  will  average  about  16  percent.  In  cream  from  w^ell-fed 
Aldemey  or  Jersey  herds  it  may  be  as  high  as  20  percent,  or  higher. 
In  cream  from  cows  indifferently  fed,  in  those  who  subsist  entirely 
upon  poor  pasturage,  the  fat  may  be  as  low  as  10  or  12  percent.  For 
infant-feeding,  gravity  cream  from  the  milk  of  grade  cows  is  preferred. 
In  using  cream  for  infant-feeding  all  the  cream  to  the  milk  line  should 
be  removed,  as  the  upper  layers  are  much  richer  in  fat  than  that 
adjoining  the  milk.  Further,  when  cream  is  mixed  with  milk  both 
must  be  of  the  same  age,  as  the  addition  of  older  bacteria-laden 
cream  to  fresh  milk  will  surely  result  in  grave  digestive  disorders. 

Centrifugal  Cream. — Centrifugal  cream  is  that  which  is  removed 
by  an  apparatus  known  as  a  separator,  which  consists  of  a  circular 
bowl  for  holding  the  milk  so  arranged  as  to  make  from  3000  to  5000 
revolutions  a  minute.  This  results  in  a  rapid  separation  of  the 
lighter  fat  from  the  milk.     The  fat  collects  near  the  center  of  the 


Io8  NUTRITION    AND    GROWTH 

bowl  and  is  removed  by  a  device  arranged  for  this  purpose.  The 
skimmed  milk  flows  outward  from  another  portion  of  the  bowl  by  a 
similar  device.  Centrifugal  cream  is  more  difficult  of  digestion  than 
gravity  cream  in  that  the  natural  emulsion  in  which  the  fat  is  h(^ld 
in  the  milk  is  destroyed  by  the  process  of  centrifuging.  Centrifugal 
cream  may  vary  greatly  in  its  fat  content,  depending  upon  the 
rapidity  of  operation  of  the  separator.  According  to  Babcock  and 
Russell,  the  proteids  also  undergo  a  change,  which  does  not  add  to 
their  nutritive  value. 

DIFFICULT  FEEDING  CASES 

Under  this  heading  will  be  considered  the  acutely  difficult  cases^ 
those  seen  in  the  newly  born  or  during  the  first  month  of  life.  Maras- 
mus and  malnutrition  will  not  be  referred  to  here,  as  these  sub- 
jects are  considered  under  their  respective  headings. 

Not  a  few  healthy  infants  for  whom  the  breast-feeding  is  impos- 
sible show  intolerance  of  cow's  milk  even  when  it  is  given  very  much 
diluted  with  lime-water  or  otherwise.  In  these  infants  the  intoler- 
ance is  usually  of  the  casein  of  the  cow's  milk.  The  child  suffers  from 
colic,  oftentimes  to  an  extreme  degree,  crying  five  or  six  or  more 
hours  out  of  every  twenty-four.  Generally  there  is  constipation.  The 
stools  are  usually  hard  and  dry,  and  when  passed,  are  often  composed 
of  broken  masses  of  fecal  matter.  In  some,  however,  there  will  be 
loose  watery  stools  containing  many  milk  curds.  The  abdomen  is 
usually  distended  and  there  may  be  vomiting,  but  this  is  seldom 
an  active  symptom.  The  child  remains  stationary  or  loses  in  weight. 
If  suitable  nutrition  is  not  forthcoming,  he  rapidly  develops  a  con- 
dition of  malnutrition  or  marasmus. 

Treatment. — Whey-feeding. — In  some  of  these  infants  the  feeding 
of  whey  (page  96)  or  cream  largely  diluted  may  be  successful  (page 
87).  In  not  a  few,  however,  the  small  amount,  about  0.3  percent, 
of  casein  w^hich  cannot  be  removed  from  the  whey  is  sufficient  to 
cause  marked  symptoms  of  indigestion.  The  addition  of  citrate  of 
soda  (page  96)  may  be  attempted  here  for  the  purpose  of  facilitating 
the  digestion  of  the  casein.  A  few  days'  trial  may  determine 
whether  it  will  be  of  any  service. 

The  Wet-nurse.— The  use  of  peptonized  milk  mixtures  is  rarely 
successful  with  these  infants.  If  the  whey  or  diluted  cream  or  the 
peptonization  of  the  food  is  not  successful,  I  invariably  advise  a  wet- 
nurse,  if  the  family  can  afford  the  so-called  luxury.  It  is  important 
in  the  management  of  one  of  these  cases  for  the  physician  to  know 
when  he  is  beaten.  A  case  should  never  be  experimented  with  to 
the  point  of  marasmus  and  exhaustion  before  securing  a  wet-nurse, 
for  by  this  time  the  digestion  may  be  so  thoroughly  deranged  that 
her  milk  will  fail  to  nourish  the  child. 

Condensed  Milk. — When  the  wet-nurse  is  impossible,  it  is  not  wise 


DIFFICULT   FEEDING    CASES 


109 


to  attempt  the  forcing  of  fresh  cow's  milk  or  cream  mixtures.  Con- 
densed milk  should  now  be  resorted  to.  The  proteid  of  condensed 
milk  is  often  very  readily  assimilated  by  the  most  delicate  infant  and 
furnishes  a  valuable  means  of  nutrition  in  not  a  few  cases  until  the 
infant  is  able  to  digest  better  food.  It  is  to  be  understood,  however, 
that  condensed  milk  is  but  a  temporary  expedient.  The  infants  will 
take  it  with  comfort,  and  temporarily  will  thrive  on  it,  oftentimes 
when  cow's  milk  in  any  dilution  or  process  of  adaptation  is  impossible. 
When  beginning  the  use  of  condensed  milk  it  is  best  to  begin  with 
small  quantities — not  more  than  one  dram  in  the  boiled  water  diluent 
of  two  or  three  ounces.  In  some  cases,  at  first,  even  one-half  dram 
answers  better.  Later  the  strength  may  be  increased  to  from  two  to 
four  drams  if  it  is  found  to  agree,  the  amount  depending  somewhat 
upon  the  age  of  the  patient.  When  the  condensed  milk  is  found  to 
agree,  in  order  to  give  as  much  nourishment  as  possible,  No.  i 
barley-water  or  Granum- water  (page  124)  may  be  used  as  a  diluent. 

Cow's  Milk. — When  the  child  has  remained  comfortable  for  three 
or  four  weeks  on  some  such  scheme  of  feeding,  with  or  without  a  gain 
in  weight,  one  feeding  daily  of  a  cow's-milk  mixture  may  replace  a 
feeding  of  condensed  milk.  A  cow's-milk  mixture  should  always  be 
given  of  a  weaker  strength  than  the  child's  age  calls  for.  In  spite 
of  the  dilution  it  may  occasion  indigestion,  colic,  and  the  passage  of 
curds.  In  such  an  event  the  condensed  milk  and  its  diluent  must 
again  be  the  sole  diet  for  two  or  three  weeks,  when  the  use  of  cow's 
milk  may  again  be  attempted.  In  case  this  one  feeding  of  cow's  milk 
is  taken  without  inconvenience,  a  second  feeding  may  replace  another 
condensed-milk  feeding  in  a  few  days  or  a  week.  In  this  way  the 
number  of  cow's-milk  feedings  may  gradually  be  increased  until  the 
child  is  taking  a  rational  diet  of  cow's  milk  alone.  I  have  a  most 
difficult  feeding  case  under  my  care  at  the  present  time.  A  six- 
months-old  baby  is  taking  daily  three  feedings  of  condensed  milk 
and  three  of  cow's  milk.  Attempts  have  been  made  to  give  him  the 
fourth  feeding  of  cow's  milk,  but  invariably  with  disastrous  results. 
He  is  slightly  under  weight,  but  is  in  a  fair  general  condition. 

I  have  successfully  managed  a  great  many  of  these  difficult 
feeding  infants  as  described  above,  the  cow's-milk  feeding  not  being 
commenced  until  the  condensed  milk  is  W'Cll  taken  and  the  child 
gaining,  when  the  cow's-milk  feeding  is  gradually  advanced  so  that 
when  the  child  is  three  months  old  it  will  be  taking  daily  and  assim- 
ilating two  or  three  feedings  of  cow's  milk ;  when  six  months  old  and 
sometimes  earlier,  he  will  be  on  entire  cow's-milk  feedings  suitable 
for  his  age .  I  have  found  this  meets  better  the  desired  end  of  complete 
cow's-milk  feeding,  and  it  is  thus  reached  sooner  than  when  small 
quantities  of  cow's  milk  are  added  to  the  condensed-milk  mixture. 

In  beginning  the  cow's  milk  it  is  best  to  give  it  at  the  first 
or  second  feeding  in  the  morning,  when  the  digestive  powers  are 


no  NUTRITION    AND   GROWTH 

stronger  than  they  are  later  in  the  day.  When  the  second  cow's-milk 
feeding  is  given  it  should  never  immediately  follow  the  first.  The 
cow's  milk  and  the  condensed  milk  should  be  alternated  until  more 
than  one-half  of  the  daily  feedings  are  of  cow's  milk. 

Idiosyncrasies  as  to  Cow's  Milk. — At  rare  instances,  cases  are 
encountered  in  which  there  exists  an  intolerance  of  cow's  milk  or 
any  form  of  food  w^hich  contains  cow's  milk,  including  condensed 
milk,  and  all  the  malted  foods  containing  desiccated  cow's  milk. 
In  such  cases  the  use  of  any  of  these  substances  as  foods  produces 
illness  of  such  an  alarming  type  as  to  necessitate  its  prompt  discon- 
tinuance.    The  only  hope  for  infants  thus  constituted  is  a  wet-nurse. 

Illustrative  Cases. — The  best  illustration  of  milk  idiosyncrasy  that 
I  have  observed  occurred  in  my  own  family.  A  healthy  full-term 
female  infant  whose  birth-weight  was  seven  pounds  twelve  ounces  was 
nursed  by  her  mother  with  indifferent  success  for  two  weeks,  when  the 
supply  failed  absolutely.  Feeding  with  a  most  carefully  prepared 
modified  cow's  milk  was  begun.  The  child  refused  the  food  and  two 
drams  were  forced.  This  was  followed,  in  a  few  moments,  by  vomiting 
and  retching,  which  continued  at  intervals  for  twenty-four  hours,  with 
collapse  and  exhaustion  to  an  extreme  degree.  A  wet-nurse  was 
secured,  the  breast  was  well  taken,  and  the  milk  agreed  perfectly. 
In  three  days  the  wet-nurse's  milk  began  to  fail  and  was  entirely 
lost  in  twenty-four  hours.  A  weak  dilution  of  condensed  milk  was 
then  given,  with  results  almost  as  disastrous  as  before.  The  child 
at  this  time  weighed  six  pounds  four  ounces  and  showed  all  the 
symptoms  of  early  marasmus.  A  second  wet-nurse  was  secured, 
whose  milk  also  failed  in  a  few  days.  Before  dismissing  her,  however, 
a  third  was  engaged,  on  whose  milk  the  child  thrived  most  satisfac- 
torily. When  three  months  of  age  a  w^eak  cow's-milk  mixture 
prepared  by  the  Walker-Gordon  Laboratory  was  given.  The  child 
refused  it,  and  one-half  ounce  was  forced.  As  on  the  previous 
occasion,  vomiting  with  prostration  bordering  on  collapse  was  the 
outcome.  The  child  vomited  at  frequent  intervals  for  twelve  hours 
and  the  breast  was  refused  for  twelve  hours  longer.  The  giving  of 
cow's  milk  was  not  again  attempted  until  the  child  was  nine 
months  old,  a  wet-nurse  being  employed.  She  was  then  strong 
and  vigorous  and  weighed  eighteen  pounds.  Two  drams  of  a  cow's- 
milk  mixture  suitable  for  a  child  three  months  of  age  were  given. 
It  produced  nausea  and  vomiting  as  though  an  equal  quantity  of 
syrup  of  ipecac  had  been  given,  but  without  any  more  serious  dis- 
turbance. At  this  time  the  wet-nurse's  milk  began  to  fail.  The 
breast-milk  nutrition  was  assisted  by  the  use  of  a  cereal  made  into  a 
thick  gruel.  Oatmeal  in  the  form  of  a  gruel  to  which  sugar  was 
added  was  given,  largelv  because  of  its  high-proteid  content.  Beef- 
juice,  scraped  beef,  and  pure  cod-liver  oil  were  also  begun  about 
this  time.     When  one  year  of  age  a  portion  of  a  soft  &gg  was  added 


STERILIZATION    AND   PASTEURIZATION    OF    MILK  1  I  I 

to  the  diet.  Zwieback  and  bread  crusts  soaked  in  sugar-water  were 
also  used.  These  sohd  substances  were  given  two  or  three  times  a 
day,  after  which  the  child  was  nursed.  Pure  cod-liver  oil  was 
almost  continuously  given  during  the  second  year.  Butter  fat 
could  be  taken  without  inconvenience  when  she  was  one  year  of  age. 
Following  out  the  above  lines  of  treatment,  the  child  was  weaned 
when  thirteen  months  of  age.  She  has  since  been  fed  with  an  entire 
absence  of  cow's  milk  from  the  diet.  She  is  now  six  years  of  age. 
Her  weight  is  fifty-five  pounds,  height  forty-eight  inches.  She  is 
normal  in  every  respect,  but  six  ounces  of  milk  given  at  one  time 
will  produce  a  coated  tongue,  foul  breath,  constipation,  and  excessive 
irritability,  which  is  entirely  foreign  to  her  nature. 

I  had  a  similar  experience  in  the  case  of  a  patient — a  boy  now 
four  years  of  age  who  has  never  been  able  to  take  cow's  milk.  He 
also  is  above  the  average  in  weight,  height,  and  vitality.  I  have 
had  a  number  of  these  cases  which  could  not  take  milk  up  to  the 
eighteenth  month  or  second  year.  I  have  had,  in  all,  five  cases 
that  could  not  tolerate  milk  in  any  appreciable  amount  until  after 
the  fifth  year  was  passed. 

STERILIZATION  AND  PASTEURIZATION  OF  MILK 

The  sterilization  and  pasteurization  of  milk,  as  the  terms  imply, 
are  for  purposes  of  preservation.  By  sterilized  milk  we  understand 
milk  that  is  heated  to  the  boiling-point  and  maintained  at  that 
temperature,  212°  F.,  for  twenty  minutes.  The  effect  of  steriHzation 
is  the  destruction  of  the  pathogenic  bacteria,  but  it  will  not  destroy 
the  spores.  Pasteurization  consists  in  heating  the  milk  to  167°  F., 
maintaining  it  at  that  temperature  for  thirty  minutes,  and  then 
quickly  cooling  it.  The  effect  of  sterilization  and  the  rapid  cooling 
is  to  kill  existing  bacteria,  thus  preventing,  temporarily,  further 
bacterial  growth  in  the  milk.  The  heating  of  milk  to  this  high 
degree  of  temperature,  212°  F.,— the  boiling-point,— produces 
certain  changes  in  the  milk.  The  lactalbumin  is  coagulated,  the 
lime  salts  are  rendered  insoluble,  and  the  casein  is  rendered  much 
more  difficult  of  digestion,  so  that  the  heating  of  milk  in  this  way 
renders  it  more  difficult  of  digestion  and  lessens  its  nutritive  value. 

Results  of  Sterilization.— Constipation  is  one  of  the  unfavorable 
results  of  sterilizing  milk.  The  peculiar  taste  produced  by  boiling  is 
another  of  the  disagreeable  features  connected  with  it.  The  cooking 
of  the  milk  destroys  certain  of  its  nutritional  properties  but  little  un- 
derstood, the  result  of  which  may  be  scurvy,  rachitis,  or  some  other 
form  of  malnutrition.  Sterilization,  however,  is  in  certain  conditions 
necessary.  The  milk  which  is  boiled  in  a  bottle  which  is  properly 
covered  "is  "  sterilized  milk,"  but  if  the  sterilization  is  to  be  carried  on 
day  after  day  an  Arnold  sterilizer  (Fig.  14)  should  be  used.  For  pur- 
poses of  pasteurization  the  Freeman  pasteurizer  (Fig.  1 5)  is  recorti- 


NUTRITION   AND   GROWTH 


mended.  Pasteurization  makes  less  change  in  the  character  of  the 
milk  content ;  consequently  there  is  less  interference  with  its  nutritive 
value.  The  temperature,  too,  167°  F..  is  sufficiently  high  to 
destroy  pathogenic  bacteria,  including  the  Bacterium  lactis  and 
the  Bacterium  aerogenes,  and  hence  acts  as  a  valuable  preservative, 
particularly  during  hot  weather.  But  heating  the  milk  to  this 
degree  exerts  little  influence  in  causing  constipation,  nor  does  it 
change  the  taste  of  the  milk. 

Pasteurization  Safest  for  Exclusive  Use. — As  to  the  feeding  of 
milk,  whether  it  shall  be  given  sterilized,  pasteurized,  or  raw,  end- 
less discussion  has  arisen  in  the  press  and  in  medical  societies.  Each 
method  has  its  advocates.  Among  the  pediatrists  at  the  present 
time,  some  contend  that  milk  should  be  sterilized,  regardless  of  the 

season  of  the  year,  the  character 
of  the  milk,  or  the  station  in  life  of 
the  patient ;  others  maintain  that 
invariably  it  should  be  given  raw, 
regardless  of  the  above-mentioned 
conditions;  while  still  others  are 
devoted  to  pasteurization.  If  any 
of  the  methods  were  to  be  used 
exclusively,  pasteurization,  being 
the  safest,  should  be  selected. 
Judging  from  my  own  experience 
in  the  matter  of  the  heating  of 
milk  for  infant  foods,  the  sub- 
ject should  be  considered  from  a 
broad  standpoint.  There  is  no 
one  way  of  heating  milk  that  is 
invariably  the  best  way.  Ac- 
cording to  my  observation,  which 
covers  every  class  of  society, 
there  are  several  factors  which  determine  which  is  the  proper  pro- 
cedure in  a  given  case. 

Raw  Milk  Preferred  if  Fresh  and  Pure. — There  is  no  doubt  what- 
ever that  the  less  the  milk  is  heated,  the  better  food  it  is  for  the 
baby,  assuming  that  it  is  clean  when  procured  and  can  be  kept  clean 
and  sweet  until  it  is  used.  (See  Cow's  Milk,  page  98.)  This  is  possible 
in  some  of  our  dairies  of  the  better  class ;  it  is  possible  with  many 
who  live  in  the  country,  or  who  go  to  the  countrv  for  the  summer 
and  who  keep  their  own  cows  or  who  get  their  milk-supply  from  a 
neighboring  source  which  they  can  control.  Under  such  conditions 
the  milk  may  be  given  raw  during  the  entire  year. 

When  the  milk  has  to  be  shipped  a  considerable  distance  during 
the  summer,  when  its  safety  depends  upon  the  industry  and  care  of 
the  employees  of  a  milk  farm,  I  find  it  advisable  to  pasteurize  the 


Fig.  14.— Arnold  Sterilizer. 


STERILIZATION    AND    PASTEURIZATION    OP    MILK  I  13 

milk  during  the  heated  term;  therefore  the  majority  of  my  private 
feeding  cases  get  raw  milk  during  eight  months  of  the  year  and  pas- 
teurized milk  four  months.  Sterilized  milk  is  never  used  among 
these  patients  except  when  preparing  for  an  ocean  voyage  (see  Milk 
for  Traveling,  page  116)  or  for  a  long-distance  journey  by  land. 
Among  out-patients,  after  feeding  many  thousands  of  them  I  find 
the  following  scheme  the  safest:  From  May  ist  until  October  ist. 
the  milk  is  boiled  (sterilized).  These  people,  most  of  them,  cannot 
afford  a  pasteurizer  or  sterilizer  or  understand  the  use  of  either. 
From  October  ist  to 
May  ist,  the  milk  is 
given  raw.  Pasteuri- 
zation would  be  pref- 
erable, but  it  is  possi- 
ble with  but  very  few 
dispensary  patients. 
Even    the    giving    of 


Fig.  13.— Freeman  Pasteurizer. 


cooked  milk,  which  unquestionablv  often  becomes  infected  after 
cooking,  is  attended  with  no  little  risk  to  the  child,  as  is  shown 
by  the  death  records  of  bottle  babies  during  the  summer.  The  giv- 
ing of  the  cheap  market  milk  raw  to  infants  of  the  tenements  during 
the  heated  term  in  any  large  citv  can  onlv  help  to  increase  the 
terrible  mortality  of  this  season. 

The  object  of  heating  the  milk  should  always  be  explained  to 
the  mother  so  that  she  may  appreciate  the  necessity  of  keeping  it 
carefully  covered  and  properly  caring  for  it  afterward.  The  idea 
is  prevalent  among  uninformed  people  that  after  sterilization  but 
little  further  protection  is  required.  When  I  am  satisfied  that  the 
out-patients  have  not  the  intelligence  or  the  requirements  for  keeping 


114  NUTRITION    AND   GROWTH 

cow's  milk  during  the  summer,  such  as  an  ice-box  and  ice,  I  discon- 
tinue the  ordinary  milk-feeding  for  the  hot  months  and  use  condensed 
milk  instead  (page  94). 

CONDENSED  MILK 
Condensed  milk  is  in  the  market  in  three  forms — fresh  condensed 
milk  sold  in  bulk,  condensed  milk  sold  in  hermetically  sealed  cans, 
and  evaporated  cream,  sold  also  in  hermetically  sealed  cans.  The 
evaporated  creams  usually  contain  no  more  fat  than  does  condensed 
milk;  in  fact,  they  are  condensed  milk  without  the  addition  of  sugar, 
which  acts  as  a  preservative.  They  are  put  up  in  small  cans  and 
soon  become  putrid  after  opening.  Therefore  the  contents  of  a 
can  should  be  used  only  on  the  day  it  is  opened.  Of  the  condensed 
milks,  I  prefer  the  sweetened  variety,  of  which  there  are  many  kinds 
showing  slight  variation  in  the  analysis.  The  Eagle  Brand  of 
Borden  is  that  which  I  usually  employ,  an  analysis  ^  of  which  showed 
it  to  contain : 

Fat 8.8  percent 

Sugar 52.2 

Total  proteid 9.3 

Total  solids 72.2 

Ash 1.9 

Water 27.8 

The  following  combinations  of  condensed  milk  with  barley-water 
may  be  found  useful  in  the  various  ages  indicated : 

Under  three  months  of  age:  Condensed  milk,  one-half  to  one 
even  teaspoonful;  barley-water,  two  to  four  ounces. 

Third  to  sixth  month:  Condensed  milk,  one  to  two  even  tea- 
spoonfuls  ;  barley-water,  four  to  six  ounces. 

Sixth  to  ninth  month:  Condensed  milk,  two  to  three  even  tea- 
spoonfuls;  barley-water,  six  to  eight  ounces. 

Ninth  to  twelfth  month:  Condensed  milk,  three  even  teaspoonfuls; 
barley-water,  eight  ounces. 

It  will  be  seen  that  when  condensed  milk  is  diluted  from  ten  to 
twenty  times,  we  have  a  food  weak  in  fat  and  weak  in  proteid.  It 
should  never  be  selected  as  a  permanent  diet  unless  poverty  neces- 
sitates it  or  unless  it  is  the  only  milk  food  the  patient  can  digest. 
For  temporary  purposes  it  is  often  useful,  as  is  shown  in 
different  portions  of  this  book  (see  index).  Where  cow's  milk  can- 
not be  used  in  a  given  case,  and  condensed  milk  must  be  continued, 
it  should  be  fortified  with  a  cereal  gruel  of  barley  or  oatmeal;  pure 
cod-liver  oil  should  also  be  given  to  make  up  for  the  deficiency  in  fat 
in  the  food. 

'Analysis  made  for  the  author  by  Dr.  Frederick   Sondern,  of  New  York. 


PEPTONIZED  MILK  II5 


PEPTONIZED  MILK 


Milk  is  peptonized,  or  predigested,  for  the  purpose  of  partially 
or  completely  digesting  the  proteid  before  it  is  given  to  the  patient. 
As  a  means  of  assistance  in  making  a  milk  food  assimilable  its  field 
of  usefulness  is  limited.  The  process  referred  to  (page  97)  has  been 
the  one  most  successful  with  me.  So-called  complete  peptonization 
produces  a  product  with  a  decidedly  bitter  taste,  and  but  few  children 
will  take  it.  Peptonized  milk,  however,  has  other  uses  than  as  a  means 
of  dailv  feeding.  Peptonized  milk  in  which  there  is  a  complete 
conversion  of  the  casein  has  been  most  useful  in  two  types  of  cases. 

For  Gavage. — During  acute  or  chronic  illness  when  a  child  cannot 
take  food  by  the  natural  method,  as  in  diphtheritic  paralysis,  or 
when  he  will  not  swallow  on  account  of  an  acute  inflammatory 
disease  of  the  throat  such  as  peritonsillitis,  retropharyngeal  abscess, 
or  retropharyngeal  adenitis,  or  when  he  is  in  a  comatose  condi- 
tion from  any  cause  except  intestinal  infection,  the  feeding  of 
completely  peptonized  milk  by  gavage  (page  134)  is  of  inestimable 
value.  In  such  conditions,  as  a  valuable  aid  in  nutrition,  frequent 
reference  is  made  to  it  throughout  this  book. 

For  Nutrient  Enema. — In  conditions  when  stomach-feeding  is 
impossible  either  by  gavage  or  the  natural  method — conditions  met 
with  in  persistent  vomiting  due  to  acute  cerebral  diseases,  in  recur- 
rent vomiting,  in  acute  gastric  indigestion — and  as  an  accessory 
means  of  feeding  when  sufifiicient  nourishment  cannot  be  taken  b}^  the 
stomach,  the  colon-feeding  of  completely  peptonized  skimmed  milk 
has  a  decided  field  of  usefulness,  and  in  this  way  I  often  employ  it. 
Feeding  by  means  of  the  bowel,  however,  is  usually  possible  in  children 
for  a  few  days  only,  because  of  the  local  irritation  produced  by  the 
nutriment  and  by  the  passage  of  the  tube.  Skimmed  milk,  pepton- 
ized, with  the  addition  of  the  white  of  egg  makes  the  best  nutrient 
enema  that  I  have  used  (page  139).  It  should  be  given  at  a  tem- 
perature between  90°  and  95°  F.  at  from  six  to  eight-hour  intervals. 
The  tube  should  be  introduced  at  least  nine  inches.  In  cases  of  re- 
current vomiting  I  have  repeatedly  seen  both  hunger  and  thirst 
relieved  by  feeding  in  this  way.  The  following  are  the  different 
methods  for  the  peptonization  of  milk. 

Peptonization.  —  Innuediate  Process.  —  Fifteen  minutes  before 
feeding  add  from  one-eighth  to  one-quarter  of  the  contents  of  a  Fair- 
child  peptonizing  tube  to  the  milk  mixture  which  is  in  the  nursing- 
bottle  ready  for  use.  Place  the  bottle  in  water  at  a  temperature  of 
from  110°  to  120°  F.,  and  let  it  remain  until  fifteen  minutes  have 
elapsed.  The  amount  of  the  powder  used  and  the  degree  of  heat  of 
the  water  depend,  of  course,  upon  the  amount  of  milk  in  the  nursing- 
bottle. 

Cold  Process. — Put  four  ounces  of  cold  water  into  a  clean  quart 


Il6  NUTRITION    AND   GROWTH 

bottle  and  dissolve  in  it,  by  shaking  thoroughly,  the  powder  con- 
tained in  one  of  the  Fairchild  peptonizing  tubes;  add  a  pint  of  cold 
fresh  milk,  shake  the  bottle  again,  and  immediately  place  it  upon  ice — 
directly  in  contact  with  it. 

The  bottle  should  always  be  well  shaken  before  and  after  pouring 
out  a  portion  of  its  contents. 

Partially  Peptonized  Milk. — Put  four  ounces  of  cold  water  and 
the  powder  contained  in  one  of  the  Fairchild  peptonizing  tubes  into 
a  clean  saucepan,  and  stir  well;  add  a  pint  of  cold  fresh  milk  and 
heat  with  constant  stirring  to  the  boiling-point.  The  heat  should 
be  so  applied  that  the  milk  will  come  to  a  boil  in  ten  minutes.  Let 
it  cool  until  lukewarm,  then  strain  into  a  clean  bottle  or  glass  jar, 
cork  tightly  and  keep  in  a  cold  place.  The  bottle  or  jar  should  always 
be  well  shaken  before  and  after  pouring  out  a  portion. 

Partially  peptonized  milk,  if  properly  prepared,  will  not  become 
bitter. 

Completely  Peptonized  Milk. — Put  four  ounces  of  cold  water  and 
the  powder  contained  in  one  of  the  Fairchild  peptonizing  tubes  into 
a  clean  quart  bottle  and  shake  thoroughly;  add  a  pint  of  cold  fresh 
milk  and  shake  again;  then  place  the  bottle  in  a  pail  or  kettle  of 
warm  water — about  115°  F.,  or  not  too  hot  to  immerse  the  hand  in 
it  without  discomfort.  Keep  the  bottle  in  the  water-bath  for  thirty 
minutes.     Put  it  immediately  upon  ice — directly  in  contact  with  it. 

MILK  FOR  TRAVELING 
In  making  long  journeys  with  infants  by  land  or  water,  the 
feeding  of  the  child  is  an  important  matter,  and  advice  is  often 
sought  by  mothers  who  wish  to  make  the  contemplated  trip  with  the 
least  possible  risk.  It  is,  of  course,  desirable  that  no  change  be  made 
in  the  milk  commonly  used,  and  there  are  means  of  treating  the 
milk  and  of  keeping  it  which  enable  us  to  assure  the  patient  of 
reasonable  safety.  It  is  my  custom  with  city  children  to  have  the 
milk  prepared  at  the  Walker-Gordon  Laboratory,  where  at  a  trifling 
expense  small  ice-boxes  can  be  obtained  which  contain  sufhcient 
space  for  a  few  days'  supply  of  milk  and  which  can  be  conveniently 
carried  on  cars  and  boats.  They  have  also  larger  boxes  with  a 
capacity  of  twelve  quarts  which  may  be  used  for  an  ocean  voyage. 
The  smaller  box  will  need  refilling  with  ice,  once  or  twice  a  day, 
which  is  usually  readily  secured.  The  larger  box  for  ocean  vovages 
is  packed  in  ice  and  placed  in  a  cold-storage  room  of  the  vessel 
and  will  not  need  repacking  during  the  trip.  The  milk  prepared 
for  a  journey  should  be  cooled  to  45°  F.  as  soon  as  it  is  drawn,  and 
kept  at  this  temperature  until  it  can  be  sterilized  at  a  temperature 
of  212°  F.  for  twenty  minutes.  It  then  should  be  cooled  rapidly  to 
at  least  50°  F.  and  kept  at  this  point  until  used.  These  directions 
can  be  carried  out  by  any  intelligent  family.     When  this  is  done  the 


Tim    PROPRIETARY   FOODS  II7 

milk  will  be  safe  for  use  for  the  time  required — from  seven  to  eight 
days.  Of  course,  laboratory  milk  is  available  for  comparatively 
few.  But  the  suggestion  as  to  the  making  of  an  ice-box  can  be 
followed  in  any  town  or  village,  so  that  a  milk  laboratory  is  not 
essential.  All  that  is  required  is  the  ice-box,  the  quart  fruit  jars 
or  quart  milk  bottles,  and  clean  milk.  Those  who  for  any  reason, 
cannot  avail  themselves  of  the  milk  thus  preserved  will  find  in  canned 
condensed  milk  a  fairly  good  substitute.  If  kept  on  ice  and  wrapped 
in  a  sterile  towel,  a  can  of  condensed  milk  may  safely  be  used  for  three 
days  after  opening.  Formulas  suited  for  the  various  months  of 
infancy  will  be  found  in  the  section  on  Condensed  Milk  (page  1 14). 

THE  PROPRIETARY  FOODS 

The  foods  on  the  market  prepared  for  purposes  of  infant-feeding 
are  almost  without  number.  From  our  knowledge  of  the  composi- 
tion of  mother's  milk  we  learn  what  nutritional  elements  and  approx- 
imately in  what  relative  proportions  these  elements  must  exist  in 
order  to  supply  the  child  with  the  food  which  nature  intended  him 
to  have.  The  examination  of  the  milk  of  thousands  of  nursing 
women  shows  that  it  ranges  from  2.5  to  4  percent  fat,  6  to  7  percent 
sugar,  and  i  to  1.5  percent  proteid.  These  figures  may  be  put  down 
as  the  normal  limits  of  human  milk,  and  they  are  so,  simply  because 
the  infant  will  thrive  and  grow  when  the  nutritional  elements  in 
approximately  the  above  proportions  are  supplied  to  him.  It  is 
within  these  limits  that  the  food  must  be  kept  in  order  that  there 
may  be  normal  growth  and  development;  though,  of  course,  wide 
variations  from  these  may  be  of  temporary  occurrence.  While 
the  child  may  exist  and  temporarily  do  fairly  well  on  a  percent- 
age of  fat  lower  than  2.5,  he  will  invariably  show  defective  growth 
if  the  proteid  remains  persistently  under  i  percent.  The  chief 
disadvantage  in  the  infant  foods  which  are  used  without  the  addition 
of  cow's  milk,  lies  in  the  fact  that  they  do  not  contain  the  nutritional 
elements  as  they  exist  in  normal  breast-milk,  and  besides,  of  neces- 
sity, they  are  all  cooked  foods. 

In  selecting  a  substitute  for  mother's  milk  (page  80)  one  point 
is  to  be  kept  in  mind,  viz.,  the  substitute  should  contain,  in  a  readily 
assimilable  form,  the  nutritional  elements  in  approximately  the 
proportions  and  forms  in  which  they  exist  in  mother's  milk.  All 
other  feeding  is  defective.  It  is  not  well  to  put  too  much  reliance 
on  the  analysis  sometimes  published  by  the  proprietary  food  manu- 
facturer. This  type  of  food  is  decidedly  weak  in  animal  fat,  for  the 
reason  that  there  is  no  means  of  keeping  more  than  a  small  percentage 
of  it  in  a  food  without  its  becoming  rancid.  When  considerable 
percentages  are  indicated  in  the  analysis  it  is  certain  that  it  does  not 
consist  of  butter  fat.  The  quantity  of  animal  milk  proteid  is  likewise 
deficient,   and  what  is  present  has  been  cooked,   thus  detracting 


Il8  NUTRITION    AND   GROWTH 

materially  from  its  value  in  infant  nutrition.  Scurvy  is  not  an 
infrequent  result  of  the  exclusive  use  of  these  foods. 

The  Uses  of  Proprietary  Dried-milk  Foods. — It  is  to  be  remembered 
that  this  type  of  food  is  condemned  because  of  its  being  an  unsuitable 
food  when  used  exclusively  and  persistently.  Hysterical  general 
condemnation  of  the  proprietary  infant  foods  is  an  injustice. 
Throughout  this  book,  the  proprietary  foods  will  be  found  mentioned 
from  time  to  time  and  their  uses  dwelt  upon.  In  constipation  in 
"  runabout"  and  older  children  who  are  on  a  general  diet,  the  impor- 
tance of  milk  in  the  nutrition  is  a  secondary  one,  and  is  often  an 
important  factor  in  the  production  of  constipation.  In  these  cases 
cow's  milk  may  be  replaced  by  one  of  the  proprietary  dried-milk 
foods  which  has  a  laxative  effect,  with  a  good  deal  of  advantage. 
I  sometimes  employ  them  further  in  other  disordered  states.  During 
acute  illness  and  in  convalescence  from  illness  and  in  certain  forms 
of  malnutrition  they  are  usually  readily  digested  and  may  help  us 
over  difficult  places. 

Proprietary  Foods  to  Which  Fresh  Cow's  Milk  is  Added. — These 
are  not  foods  in  the  usual  acceptation  of  the  term,  and  if  they  are 
used  alone  independent  of  milk  the  patient  will  soon  present  a  sorry 
spectacle.  They  are  sugars  largely,  being  composed  of  maltose 
and  dextrose,  which  are  derived  from  starch.  Some  contain  a  con- 
siderable quantity  of  unconverted  starch.  When  added  to  the 
water  and  milk  mixtures  they  furnish  the  soluble  carbohydrates  and 
free  starch,  and  thus  fulfil  this  function  in  the  food  with  as  good 
results  as,  but  usually  no  better  than,  would  milk-sugar  and  a  cereal 
gruel.  Maltose  is  a  laxative  sugar.  In  case  of  constipation  in  the 
bottle-fed  it  may  replace  the  milk-sugar  in  equal  quantity,  and  as 
such  may  be  used  with  decided  advantage  in  some  cases.  In  other 
cases  this  change  to  maltose  is  without  effect.  The  claim  that 
when  added  to  cow's  milk  these  proprietary  foods  increase  the  lia- 
bility to  scurvy  is  without  foundation.  If  the  milk  is  given  uncooked, 
the  child  will  not  have  scurvy,  regardless  of  the  nature  of  the 
carbohydrate;  if  the  milk  is  heated  to  i6o°  or  170°  F.,  the  child  may 
have  scurvy  regardless  of  the  carbohydrates. 

The  exploiting  of  photographs  of  crowing,  fat,  red-cheeked 
babies  which  are  used  to  illustrate  the  supposed  virtues  of  this  or 
that  manufacturer's  food  composed  principally  of  maltose,  is  not  a 
very  high-minded  procedure  on  the  part  of  the  manufacturer  who 
thus  stoops  to  steal  the  credit  which  belongs  to  a  cow!  According 
to  my  observation,  the  statement  that  the  addition  of  maltose  to 
cow's  milk  facilitates  its  digestion  is  unfounded.  I  have  tried  it  in 
many  cases,  but  have  never  been  able  in  consequence  to  use  a  stronger 
cow's-milk  mixture,  a  higher  proteid.  The  true  test  of  such  a  meas- 
ure is  its  use  in  the  delicate,  and  in  difificult  feeding  cases,  and  not  in 
well  babies  who  thrive  regardless  of  the  carbohydrate  employed. 


CEREAL   GRUELS :     STARCII-FEEDING 


119 


The  maltose  preparations,  then,  in  the  sense  that  they  may  contain  a 
small  amount  of  proteid  and  a  laxative  sugar,  are  useful  and  to  be 
recommended  when  such  a  carbohydrate  is  needed. 

The  Proprietary  Beef  Foods.— Numerous  preparations  of  this 
nature  are  on  the  market  and  there  has  been  abundant  opportunity 
to  test  their  value.  Without  going  into  a  lengthy  discussion  as  to 
how  and  under  what  conditions  these  preparations  have  been  used, 
it  is  sufficient  to  say  that  as  a  means  of  nutrition  in  children  they 
play  a  very  unimportant  part.  Their  principal  use  is  in  illness,  in 
which  they  act  as  a  stimulant,  and  to  a  less  degree  as  a  food.  They 
all  make  weak  proteid  mixtures  when  diluted  so  that  the  child  can 
take  them.  The  possibility  of  supplying  any  great  amount  of 
nutrition  to  the  economy  by  their  use  is  small ;  occasionally,  however, 
they  may  be  used  to  advantage.  When  milk  is  withdrawn  they  may 
be  added  to  the  cereal  gruel  substitute.  If  there  is  diarrhea,  great 
care  must  be  exercised,  as  the  proprietary  beef  preparations  as  well 
as  beef-juice  may  increase  it.  On  account  of  the  creatinin  which 
they  contain,  they  should  not  be  given  in  any  of  the  forms  of  nephri- 
tis. Another  feature  which  limits  their  use  is  that  a  child  soon  tires 
of  them.  They  can  rarely  be  given  more  than  two  or  three  times  in 
twenty-four  hours.  Valentine's  is  the  preparation  I  usually  select. 
It  may  be  given  in  solution — one-quarter  to  one-half  teaspoonful 
to  six  ounces  of  the  diluent. 

CEREAL  GRUELS?    STARCH-FEEDING 

Much  discussion  has  taken  place  during  the  past  few  years  as  to 
the  use  of  cereals  in  infant-feeding. 

The  cereals  consist  of  plant  embryos  surrounded  by  a  mass  of 
highly  nutritious  proteids  and  carbohydrates  in  the  form  of  starch 
which  nourishes  the  embryonic  plant  until  it  becomes  rooted  in  the 
ground.  As  the  developing  plant  needs  nourishment  it  converts 
the  starch  into  dextrin  and  maltose.  Cereals  are  analogous  to 
eggs  in  that  the  germ  is  packed  away  in  a  supply  of  exceedingly 
nutritious  food  which  in  the  process  of  development  it  converts  into 
tissue.  Almost  all  of  the  prepared  infant  foods  are  made  from  cereal 
flours,  with  or  without  the  addition  of  a  little  dried  milk  or  sugar; 
or  from  cereals  in  which  the  starch  has  been  transformed  into  dextrin 
and  maltose.  The  proprietary  meal  foods  which  consist  of  baked 
flours  of  different  kinds  are  useful  aids  in  infant-feeding  and  most 
useful  as  milk  substitutes  when  milk  must  temporarily  be  withheld. 
The  conversion  of  starch  into  dextrin  by  the  baking  process  is  so 
slight  that  it  may  be  ignored.  Robinson's  barley  flour,  Cereo  Co.'s 
barley  flour  and  the  other  gruel  flours,  and  Imperial  Granum  (baked 
wheat  flour)  require  boiling  before  use.  They  may  be  prepared 
according  to  the  instructions  given  in  the  formulary   (page   123). 

It  is  my  custom  in  bottle-feeding  to  begin  with  a  cereal  from  the 


I20  NUTRITION   AND   GROWTH 

fifth  to  the  seventh  month,  by  using  a  cereal  water  as  a  dihient  of 
the  milk  mixture.  For  this  purpose  barley  or  granum  is  usually 
employed.  Very  often  in  out-patient  work  I  begin  with  a  cereal 
diluent  very  early  in  life  in  order  to  make  the  food  mixture  more 
nutritious.  This  method  of  feeding  is  useful  when  accurate  modi- 
fications are  not  possible  and  when  the  child  for  any  reason  cannot 
take  a  milk  formula  as  strong  as  its  age  and  nutritional  requirements 
demand.  Such  cases  are  frequently  seen  in  the  marasmic,  the 
malnutrition,  and  the  difficult  feeding  class.  The  addition  of 
two  or  three  tablespoonfuls  of  flour  to  the  daily  food  will  increase 
its  nutritive  value  not  a  little.  That  boiled  starch  may  be  digested 
by  the  youngest  and  most  marasmic  infant  has  been  proved  under 
my  own  observ'ations. 

The  principal  use  of  these  flours,  however,  is  in  the  gastro-enteric 
diseases,  where  they  may  with  safety  replace  the  milk  for  considerable 
periods  of  time.  In  the  treatment  of  the  acute  intestinal  diseases 
their  uses  are  repeatedly  referred  to.  By  eliminating  milk  from  the 
diet  and  giving  carbohydrates,  a  putrefactive  culture-field  is  removed 
and  a  less  favorable  soil  is  furnished  for  the  development  of  the 
intestinal  bacteria;  further,  there  are  no  by-products  formed  to 
produce  intestinal  toxemia  or  kidney  irritation.  Two  even  table- 
spoonfuls  of  these  flours  to  one  pint  of  water  give  approximately  a 
food  strength  of  0.07  percent  fat,  0.3  percent  proteid,  2  percent  car- 
bohydrate. In  order  to  increase  the  nutritive  value,  cane-sugar  may 
be  added  in  sufficient  quantity  to  bring  the  carbohydrate  percentage 
up  to  five.  The  addition  of  the  sugar  also  makes  the  cereal  more 
palatable,  and  it  will  therefore  be  taken  more  readily  by  the  patient. 

During  an  invasion  of  scarlet  fever,  pneumonia,  or  any  of  the 
illnesses  of  childhood  which  may  be  accompanied  by  great  prostra- 
tion, the  usual  foods,  whatever  their  nature,  should  be  withheld,  as 
the  cereal  gruel  alone  or  mixed  with  chicken  or  mutton  broth  fur- 
nishes a  very  satisfactory  substitute.  Likewise  later  in  the  disease 
it  is  never  well  to  give  full  milk  while  fever  and  prostration  are 
present.  A  useful  field  for  the  cereal  gruels  is  as  diluents  of  the  milk 
in  conditions  where  this  combination  must  often  furnish  the  nutrition 
for  days.  The  use  of  the  baked-flour  gruels,  with  sugar  or  without, 
as  a  means  of  nutrition  should  be  continued  only  during  the  active 
symptoms  of  the  disease,  whether  it  is  scarlet  fever  or  one  of  the 
intestinal  diseases.  In  no  sense  are  these  gruels  advocated  as  ex- 
clusive foods  for  infants  or  for  growing  children.  I  have  seen  many 
cases  where  this  error  has  been  made  with  most  disastrous  results. 

The  Infant's  Capacity  for  Starch  Digestion  Proved  by  Experi- 
ment.— It  has  been  claimed  with  more  or  less  tenacity  by  different 
writers  that  the  young  infant  possesses  no  capacity  for  starch 
digestion.  During  the  past  year  a  study  of  starch  digestion  in 
infants  of  different  ages  was  undertaken  at  my  suggestion  at  the 


CEREAL    gruels;    STARCII-FEEDIXG  12  1 

New  York  Infant  Asylum.  In  the  first  series  of  sixty  cases,  324 
stool  examinations  were  made,  for  purposes  of  observation  on  ex- 
clusively starch-fed  children. 

Boiled  barley  flour  in  the  form  of  a  gruel  in  amounts  of  from  142  to 
1560  grains  in  twenty-four  hours  was  given,  the  usual  quantity  being 
from  400  to  500  grains.  In  testing  for  starch  in  the  stools,  the 
von  Jaksch  iodin  method  was  employed.  In  thirty-three  cases 
the  stools  were  persistently  negative,  five  examinations  having  been 
made  on  five  successive  days;  of  these,  eleven  were  under  six  months 
of  age.  One,  who  was  nineteen  days  old,  took  142  grains  of  starch 
daily,  and  the  stools  were  negative  to  the  two  examinations  made 
on  two  successive  days.  One,  twenty-one  days  old,  took  225  grains 
every  twenty-four  hours.  To  one,  five  months  and  twenty-six  days 
old,  375  grains  daily  wefe  given.  In  each  of  these  cases  five  examin- 
ations were  made,  all  being  negative.  To  one  five  and  a  half 
months  of  age  450  grains  were  given  for  three  successive  days. 
It  was  then  decided  to  increase  the  starch  and  test  his  digestive  capac- 
ity. There  were  accordingly  given  him  1 560  grains  daily  for  two 
days.  The  stools  failed  to  respond  to  the  iodin  test.  One  was  one 
month  and  twenty-two  days  old.  The  patient  was  thin  and  he  had 
diarrhea.  Four  hundred  grains  were  given  the  first  day,  followed 
by  a  negative  stool.  Three  hundred  and  ninety  grains  were  given 
on  each  of  four  successive  days,  the  stools  remaining  negative.  To 
another  child,  one  month  and  nineteen  days  old.  185  grains  were  given 
for  three  days,  with  stools  negative.  The  starch  was  then  increased  to 
300  grains  for  two  days,  the  stools  still  remaining  negative.  In  seven 
cases  the  stools  were  persistently  positive,  showing  the  presence 
of  starch  in  considerable  amount  at  each  examination.  In  twenty 
cases  the  reactions  were  sometimes  positive  and  sometimes  negative. 
From  these  examinations  it  was  shown  that  of  the  sixty  cases  in 
question,  forty-one  showed  a  good  starch  capacity  and  nineteen  an  in- 
different or  poor  starch  capacity.  That  some  of  the  starch  may  have 
undergone  fermentation  in  the  intestine  is,  of  course,  possible.  How- 
ever, it  could  not  have  been  a  factor  of  great  consequence,  for  the  pa- 
tients did  not  show  more  than  the  usual  bowel  distention.  Dextrin 
was  present  at  times  in  over  one-half  the  cases,  thus  showing  only 
a  partial  conversion  from  the  presence  of  a  starch  enzyme.  In  all 
these  children  subjected  to  the  test,  a  fair  degree  of  nutrition  was 
maintained  during  the  period  of  the  exclusive  starch  diet.  Several 
of  the  starch-fed  infants  in  which  the  stools  were  negative  to  iodin 
were  very  young  and  very  delicate.  This  led  us  to  undertake  a 
study  of  the  stools  of  infants  fed  exclusively  on  the  breast,  with  a 
view  of  determining,  if  possible,  the  presence  of  starch-digesting 
enzyme  or  enzymes  in  the  feces,  161  tests  being  made  of  the  stools 
of  twenty-six  children.  The  ages  were:  under  two  weeks,  twenty- 
two  ;  between  one  and  two  months,  three ;  one,  the  oldest  child,  was 


122  NUTRITION    AND   GROWTH 

two  and  one-half  months  old.  The  tests  were  conducted  as  follows: 
A  solution  of  starch,  i  :  500,  was  boiled  for  fifteen  minutes.  From 
one  to  four  drams  of  this  solution  were  then  put  into  a  test-tube,  and 
to  this  a  dilute  Lugol  solution  was  added  and  the  tube  marked  for 
control.  To  another  boiled  solution  of  starch  of  similar  strength, 
Fehling's  solution  was  added  to  determine  the  presence  of  sugar, 
which,  of  course,  was  absent.  In  another  tube  a  portion  of  feces 
in  plain  boiled  water  was  tested  for  sugar  and  always  found  negative. 
The  observations  were  thus  protected  by  three  controls.  In  still 
another  tube  an  equal  amount  of  a  i :  500  starch  solution  was  boiled 
for  fifteen  minutes  and  a  definite  amount  of  feces  by  weight  was 
added.  The  contents  were  then  thoroughly  shaken  and  placed  in  a 
water-bath,  which  was  maintained  at  a  temperature  of  100°  F.  for 
one-half  hour.  The  solution  was  then  tested  for  sugar  with  Fehling's 
solution.  In  every  case  the  presence  of  sugar  was  indicated,  thus 
proving  the  presence  of  something  in  the  feces  which  transformed 
the  starch  into  maltose.  The  observ^ations  agree  with  those  of 
von  Jaksch,  who  proved  a  starch-converting  ferment  in  twenty-eight 
out  of  thirty  cases,  and  with  those  of  Moro,  who  proved  the  same 
thing  in  thirty-eight  out  of  forty  cases. 

It  was  found  that  the  converting  capacity  of  the  feces  for  starch 
was  in  the  proportion  of  one  grain  of  feces  to  about  one-twentieth 
grain  of  starch,  this  amount  being  required  for  the  complete  con- 
version of  the  starch  into  sugar.  In  one  case  there  was  a  capacity 
of  but  one-sixtieth  grain  of  starch  to  one  grain  of  feces.  In  three, 
one  grain  of  feces  converted  one-tenth  grain  of  starch.  When 
stronger  starch  solutions  were  used,  there  was  a  response  both  with 
the  Lugol  and  Fehling  solutions,  showing  a  partial  conversion.  In 
three,  the  examinations  began  on  the  day  of  birth  and  were  continued 
for  several  days,  four  examinations  being  made  in  each  case.  Six 
were  commenced  on  the  second  day  and  continued  for  four  days. 
One  premature  baby  (eight  months)  which  lived  six  da^^s  and 
weighed  four  pounds  four  ounces  showed  a  power  of  conversion  of  one 
grain  of  feces  to  one-thirty-second  grain  of  starch. 

Excluding  bacteria  of  feces  and  the  ptyalin  of  the  saliva,  it  would 
seem  that  the  succus  entericus  and  the  pancreatic  juice  were  respon- 
sible for  the  very  active  diastatic  ferment. 

Zweifel  and  Korwin  were  unable  to  extract  a  diastatic  enzyme 
from  the  pancreas,  in  infants  under  three  weeks  old,  and  concluded 
therefore  that  none  existed.  Their  methods  cannot  be  accepted 
at  the  present  time  as  establishing  this  point,  as  the  glands  were 
macerated  and  placed  in  distilled  water,  in  some  instances  for  only 
one-half  hour,  and  then  mixed  with  a  strong  starch  solution.  Moro 
followed  along  the  lines  laid  down  by  Zweifel  by  using  distilled 
water,  though  the  maceration  was  continued  for  a  much  longer 
time,  and  in  ten  infants  under  three  months  of  age  proved  a  diastase 


FOOD    FORMULAS  I  23 

in  the  pancreatic  extract  in  seven.  In  two  of  these  the  infants 
died  at  birth.  One  lived  fourteen  days.  Four  were  between  one 
and  three  months  of  age.  We  now  know  that  much  stronger  ex- 
tracts of  the  pancreas  are  to  be  obtained  when  the  organ  is  cut  into 
small  pieces,  ground  with  sand  in  a  mortar,  and  macerated  in  a  solu- 
tion of  15  percent  alcohol  or  40  percent  glycerin.  Furthermore, 
it  is  not  logical  to  compare  with  a  dead  organ  the  active  functionating 
pancreas  of  a  living  child  under  the  stimulating  influence  of  food  in 
the  intestine.  Our  own  observations  as  to  the  elaboration  of  pan- 
creatic extract  and  the  succus  entericus  have  not  been  carried  far 
enough  to  warrant  any  authoritative  statement  based  on  the  findings ; 
but  the  claim  that  the  diastase  is  furnished  by  the  mother's  milk  is 
negatived  to  a  great  extent  by  the  fact  that  the  feces  extract  from 
meconium  stools  was  as  active  before  breast-feeding  as  later. 

It  will  be  seen  from  the  foregoing  that  the  majority  of  infants 
of  tender  age  are  able  to  digest  starch.  With  not  every  infant  is 
this  possible,  and,  according  to  this  report,  starchy  foods  thus  resem- 
ble every  other  substitute  feeding.  Not  every  infant  by  any  means 
can  take  cow's  milk  or  asses'  milk  or  goat's  milk;  but  that  starchy 
foods  may  be  added  with  benefit  to  infant  milk  foods  in  a  great 
majority  of  the  cases,  and  that  they  may  be  used  with  benefit  as  a 
substitute  for  these  foods  in  illness,  is  established  beyond  all  question, 
both  experimentally  and  clinically. 

FOOD  FORMULAS 

Beef-juice. — Take  a  round  steak,  cut  into  pieces  the  size  of  a 
horse-chestnut,  place  in  a  buttered  pan  in  a  hot  oven,  and  bake  for 
fifteen  minutes ;  remove  from  the  pan  and  press  out  the  blood ;  add 
salt  to  the  taste. 

Beef,  Mutton,  and  Chicken  Broth. — Take  one  pound  of  meat 
free  from  fat,  cook  for  three  hours  in  one  quart  of  water,  adding 
water  from  time  to  time,  so  that  when  the  cooking  is  completed 
there  will  be  one  quart  of  broth.  When  the  broth  is  cool,  remove  the 
fat,  strain,  and  add  salt  to  the  taste. 

Scraped  Beef.— Broil  round  steak  slightly  over  a  brisk  fire. 
Split  the  steak  and  scrape  out  the  pulp,  using  a  dull  knife. 

Egg-water. — The  white  of  one  egg,  thoroughly  beaten  in  one 
pint  of  cold,  boiled  water;  strain;  add  salt  to  the  taste. 

Oatmeal  Jelly.— Oatmeal,  four  ounces;  water,  one  pint;  boil  for 
three  hours  in  a  double  boiler,  water  being  added,  so  that  when 
the  cooking  is  completed  a  thin  paste  will  be  formed.  This  while 
hot  is  forced  through  a  colander  to  remove  the  coarser  particles. 
When  cold,  a  semisolid  mass  will  be  formed. 

Wheat  Jelly  and  Barley  Jelly.— Wheat  jelly  and  barley  jelly 
are  made  in  the  same  way  as  oatmeal  jelly,  using  cracked  wheat  or 
barley  grains. 

Barley-water   (No.   i).— Robinson's  barley  flour  or  Cereo  Co.'s 


124 


NUTRITION    AND   GROWTH 


barley  flour,  one  rounded  tablespoonful ;  water,  one  pint.  Boil 
thirty  minutes ;  strain ;  add  water  to  make  one  pint. 

In  making  Barley-water  No.  2,  two  tablespoonfuls  of  the  flour 
are  used. 

Rice-water  (No.  i). — Rice,  one  tablespoonful;  water,  one  pint; 
boil  three  hours,  adding  water  from  time  to  time,  so  that  there  is 
one  pint  of  rice-water  at  the  end  of  the  three  hours. 

In  making  Rice-water  No.  2,  two  tablespoonfuls  of  rice  are  used. 

Dextrinized  Barley-water. — Robinson's  barley  flour  or  Cereo 
barley  flour,  three  tablespoonfuls;  water,  one  pint;  boil  twenty 
minutes;  add  water  to  make  a  pint.  When  lukewarm  (100°  F.), 
add  one  teaspoonful  of  Cereo ;  strain ;  this  changes  the  starch  into 
dextrinized  maltose. 

Oatmeal-water  (No.  i). — Oatmeal,  one  tablespoonful;  water, 
one  pint;  cook  three  hours  and  add  water  to  make  one  pint. 

In  making  Oatmeal- water  No.  2,  two  tablespoonfuls  of  oatmeal 
are  used. 

Imperial  Granum-water  (No.  i). — Imperial  Granum,  one  table- 
spoonful; water,  one  pint;  cook  three  hours  and  add  water  to  make 
one  pint. 

In  making  Granum-water  No.  2,  two  tablespoonfuls  of  Granum 
are  used. 

Percentage  Gruel  Flours. — There  has  recently  been  put  on  the 
market  in  tin  boxes,  the  covers  of  which  are  used  as  measures,  a 
series  of  flours,  especially  made  for  preparing  cereal  gruels  and 
jellies  of  known  percentage  composition.  On  the  labels  are  given 
only  the  cooking  directions  for  preparing  plain  or  dextrinized  gruels, 
and  their  composition  when  different  quantities  of  flour  are  used 
as  follows : 


APPROXIMATE  COMPOSITION  OF  GRUELS  MADE  FROM  CEREO  CO.'S 
GRUEL  FLOURS. 


Barley. 

Legume.i 

Oat. 

Wheat. 

'S 

hi 

i 

ll 

il 

1 

ii 

<Z  2 

U    l^ 

d-a 

2 

cS-o 

,"!-a 

£ 

'-'^ 

£ 

"^^ 

^.s- 

£ 

U  >• 

i^    ounce    flour    to   quart   of 

water 

O.I2f'. 

o.6ofc        0 

igf. 

■  o.53r*        0 

12^ 

o.e&fc      0 

laf. 

0.62f. 

%    ounce    flour    to   quart   of 

water 

0.24^ 

20^        0 

39f« 

1.06^        0 

2Af> 

1.20^      0 

20^ 

1.25fi 

%.    ounce    flour    to   quart   of 

water 

0.36^* 

9^c        0 

58/. 

159^        0 

z(4 

i.Sof.        0 

3of» 

i.m 

I      ounce   flour    to    quart   of 

water 

0.48^, 

40^        0 

78;^ 

2.12!4           0 

48r. 

2.40;^      0 

4o?J 

2.50^ 

2      ounces   flour  to   quart  of 

water 

0.96^ 

80^        I 

56fi 

4.24fe         0 

9(4 

4.So!i       0 

Soft 

s.oor* 

3     ounces   flour  to   quart  of 
water 

i.445« 

20^        2 

34''* 

6.36^    I 

44!^ 

■J.2C4           I 

20fc 

7.50;^ 

4     ounces  flour  to  quart  of 

^^  ^ 

1.99^ 

6c4        3 

12^ 

8.40^    1 

92f, 

9.6054     I 

eoi, 

lO.OOfe 

Made  from  equal  parts  of  peas,  beans,  and  lentils. 


HABITUAL    LOSS    OF    APPETITE  1 25 

Whey. — Put  one  pint  of  fresh  milk  into  a  saucepan  and  heat  it 
lukewarm,  not  over  100°  F. ;  then  add  two  (2)  teaspoonfuls  of  Fair- 
child's  essence  of  pepsin  and  stir  just  enough  to  mix.  Let  it  stand 
until  firmly  jellied,  then  beat  with  a  fork  until  it  is  finely  divided; 
strain,  and  the  whey,  the  liquid  part,  is  ready  for  use. 

Junket. — To  one  pint  of  fresh  milk  add  two  teaspoonfuls  of 
sugar.  Allow  it  to  stand  over  a  fire  until  the  temperature  is  100°  F. ; 
then  add  vanilla  as  a  flavoring  and  allow  it  to  stand  until  the  curd 
is  set,  when  it  should  be  placed  upon  ice. 

HABITUAL  LOSS  OF  APPETITE 

The  growing  child,  like  the  adult,  not  only  requires  sufficient 
nourishment  to  sustain  life,  but,  in  addition  to  this,  an  extra  amount 
to  supply  the  demands  of  growth.  Proportionate  to  their  size, 
therefore,  all  growing  animals  require  more  food  than  do  those  that 
have  reached  maturity.  The  young  child  is  naturally  such  a  very 
hungry  animal  that  ample  feeding  is  absolutely  essential.  Therefore, 
when  there  is  a  habitual  loss  of  appetite  so  that  the  child's  entire 
life  may  be  unfavorably  influenced,  we  must  realize  the  fact  that 
the  condition  is  abnormal  and  strive  to  discover  the  cause  and 
apply  the  remedy. 

Physicians  are  often  consulted  by  parents  whose  children  are 
suffering  temporarily  or  persistently  from  loss  of  appetite — a  con- 
dition usually  associated  with  secondary  anemia  and  asthenia. 
The  child  apparently  is  not  ill,  he  may  be  active  and  playful,  but 
he  tires  easily.  The  sleep  ordinarily  is  sound  and  refreshing  but  the 
child  must  be  coaxed  to  eat.  Oftentimes  he  will  take  food  only 
when  his  attention  is  diverted  by  a  story  or  a  toy.  He  usually  eats 
for  the  entire  family,  taking  a  mouthful  each  for  father  and  mother, 
for  the  coachman,  and  for  the  cook!  Three  or  four  times  a  day, 
depending  upon  the  number  of  meals,  this  coaxing,  entertaining 
process  has  to  be  gone  through  with.  Occasionally  in  children  with 
habitually  poor  appetites  for  food  in  general  there  will  be  a  history 
of  excessive  milk-drinking.  From  three  to  five  glasses  of  milk  may 
be  taken  daily  and  all  other  food  refused.  When  milk  forms  the 
principal  or  only  article  of  nourishment  after  the  eighteenth  month, 
children  will  invariably  show  evidences  of  malnutrition.  They  are 
apt  to  be  pale  and  sallow,  with  flabby  muscles.  The  most  frequent 
cause  of  loss  or  lack  of  appetite  is  too  frequent  feeding.  It  is  not 
at  all  uncommon  to  see  children  from  two  to  four  years  of  age  who 
are  being  fed  six  or  seven  times  in  twenty-four  hours,  the  argument 
of  the  parents  being  that:  "The  child  takes  so  little  food,  he  ought 
to  take  it  oftener."  With  increasing  age,  more  and  stronger  food 
is  required  at  less  frequent  intervals.  In  other  cases  children  may 
not  get  their  regular  feedings  at  such  frequent  interv^als,  but  are 
generously  supplied  between  meals  with  candy,  cake,  crackers,  and 


126  NUTRITION    AND   GROWTH 

fruits.  Unsuitable  food  may  be  the  cause  of  a  habitually  poor  appe- 
tite. Children  of  tender  age  who  are  regularly  fed  from  the  adult 
table  with  heavy  adult  food,  oftentimes  improperly  cooked,  soon 
suffer  from  loss  of  appetite.  Children  who  are  poor  eaters  usually 
have  the  associated  ailment,  constipation.  Too  close  confinement 
indoors  is  not  infrequently  associated  with,  if  not  a  direct  cause  of, 
lack  of  appetite.  Children  who  are  kept  uninterruptedly  in  the 
house  for  weeks  at  a  time  invariably  have  poor  appetites. 

Treatment. — In  order  to  emphasize  a  point  in  teaching,  when  treat- 
ment is  under  consideration,  I  have  sometimes  found  it  useful  to  state, 
first,  what  not  to  do.  Do  not  give  these  children  drugs  as  a  means  of 
inducing  an  appetite  until  all  other  means  have  failed.  The  only 
medication  that  should  be  permitted  is  some  simple  laxative.  There 
must  be  one  evacuation  of  the  bowels  daily.  The  aromatic  fluid 
extract  of  cascara  sagrada,  from  one  to  two  drams,  given  daily  at 
bedtime,  or  from  three  to  five  ounces  of  the  citrate  of  magnesia 
given  before  breakfast,  ordinarily  answers  well. 

Fresh  Air. — Every  "runabout"  child  should  spend  at  least  five 
hours  daily  in  the  open  air,  regardless  of  the  season  of  the  year. 
During  very  inclement  weather  in  winter  indoor  airing  (see  page 
36)  is  a  most  satisfactory  substitute. 

Diet. — An  important  step  in  the  treatment  is  in  the  regulation  of 
the  feeding  hours.  A  child  from  twelve  to  fifteen  months  old  re- 
quires five  feedings  daily  (see  Dietary,  page  128).  Ordinarily,  for 
"  runabout"  children  from  the  fifteenth  to  the  twenty-fourth  month, 
four  meals  daily  are  necessary.  After  the  second  year,  only  three 
meals  should  be  given.  All  feedings  should  be  given  at  a  definite 
time  each  day,  which  should  never  be  deviated  from.  Nothing  what- 
ever except  water  should  be  allowed  between  meals.  My  next  step, 
in  case  these  regulations  fail,  is  to  place  the  child  temporarily  on  a 
markedly  reduced  diet.  No  solid  food,  such  as  meat,  eggs,  bread- 
stuffs,  vegetables,  or  fruits,  is  allowed.  The  mother  must  be  given 
the  directions  both  orally  and  in  writing.  Milk,  gruels,  and  broths 
should  comprise  the  nourishment. 

If  the  case  is  one  of  milk  habit,  then  the  milk  must  be  entirely 
cut  off,  and  broth,  thin  gruel,  dry  bread,  or  zwieback  substituted. 
The  mother  is  instructed  to  return  with  the  child  in  two  days.  In 
the  great  majority  of  instances  the  report  after  forty-eight  hours  is 
that  the  child  is  ravenously  hungry.  When  such  is  the  case  freer 
feeding  is  allowed,  but  under  the  same  strict  observance  of  feeding 
inter\'als,  with  absolutely  no  feeding  between  meals.  It  is  extremely 
rare  to  meet  a  case  of  habitual  loss  of  appetite  which  will  not  respond 
to  this  simple  method  of  treatment. 

Change  of  Climate. — Occasionally  a  child  is  brought  for  treatment 
who  fails  to  show  the  least  evidence  of  disease  and  yet  will  not  re- 
spond to  proper  dietetic  and  hygienic  measures.     For  such,  a  change 


COMMON    ERRORS    IN    FEEDING  1 27 

of  climate  in  addition  to  proper  methods  of  feeding  has  been  found 
advisable.  A  change  from  the  city  to  the  country;  or  from  the 
country  inland  to  the  seashore,  has  been  followed  by  a  decided 
improvement.  When  such  changes  are  impossible,  or  when  proper 
dietetic  regulations  are  impracticable,  as  with  our  dispensary  patients, 
medication  may  be  of  service. 

Tonics. — In  my  experience  the  best  medicinal  means  of  improving 
the  appetite  is  a  solution  of  citrate  of  iron  and  quinin  in  sherry  wine, 
one  grain  of  the  citrate  of  iron  and  quinin  being  dissolved  in  one-half 
dram  of  sherry  wine  and  given,  well  diluted,  before  meals.  This 
dosage  will  answer  for  children  over  eighteen  months  of  age.  For 
younger  children,  one-half  grain  of  the  citrate  of  iron  and  quinin  in 
one-half  dram  of  sherry  wine,  well  diluted,  may  be  given.  If  this 
is  not  successful  one  minim  of  dilute  hydrochloric  acid,  one-half 
minim  of  the  tincture  of  nux  vomica,  and  two  teaspoonfuls  of  water 
may  be  given  before  meals  to  children  over  fifteen  months  and 
under  two  years  of  age.  After  the  second  year  two  minims  of  the 
dilute  hydrochloric  acid  and  one  minim  of  nux  vomica  before  meals 
in  three  teaspoonfuls  of  water  may  be  given. 

There  remain  also  to  be  considered  under  this  head  not  a  few 
children  who  habitually  suffer  from  poor  appetite  who  are  below  the 
average  in  every  respect.  This  type  of  child  is  considered  in  detail 
under  the  heading  of  The  Care  of  the  Delicate  Child  (page  142). 

COMMON  ERRORS  IN  FEEDING 

In  the  bottle-fed  the  most  frequent  error  is  overfeeding,  or  a 
stronger  mixture  is  given  than  the  child  is  able  to  digest.  Particu- 
larly is  this  apt  to  be  the  case  at  the  commencement  of  bottle-feeding. 
The  amount  is  usually  too  large  and  the  intervals  between  the 
feedings  are  almost  invariably  too  short.  Children  of  the  same 
age  cannot  all  be  fed  alike.  Artificially  fed  babies  of  equal  health 
and  vigor,  but  of  considerably  varied  size  and  weight,  will  require 
food  of  approximately  the  same  strength  and  the  same  intervals 
between  feedings ;  but  the  larger  the  child,  the  greater  the  quantity 
of  food  required.  Thus,  the  quantity  given  at  one  feeding  for  a 
child  weighing  thirteen  pounds  at  the  sixth  month  will  not  be  suffi- 
cient for  a  child  of  the  same  age  weighing  sixteen  pounds. 

The  quantity  of  food  for  each  feeding  for  an  average  baby 
weighing  fifteen  pounds  at  six  months  is  about  six  ounces,  and  this 
quantity  should  be  diminished  one-half  ounce  for  every  pound  under 
this  weight  until  the  total  quantitv  is  reduced  to  four  ounces ;  and 
for  every  pound  over  fifteen,  one-half  ounce  should  be  added  to  each 
feeding  until  the  total  is  increased  to  nine  ounces.  The  number  of 
feedings  in  twenty-four  hours  should  be  the  same  for  all  young^ 
children  of  the  same  age.  In  the  table  of  food  formulas  given  on 
page  92,  only  the  average  child  of  average  weight  is  considered. 


128  NUTRITION    AND    GROWTH 

AGE  OF  CHILD,  SIX  MONTHS. 
Weight  of  Child.  Quantity  for  Each  Feeding. 

1 1  pounds 4     ounces 

1 2  pounds • 4^  ounces 

13  pounds 5     ounces 

14  pounds 5-V  ounces 

1 5  pounds 6     ounces 

16  pounds 6  f  ounces 

1 7  pounds 7     ounces 

1 8  pounds 7  V  ounces 

1 9  pounds 8     ounces 

20  pounds 8^  ounces 

2 1  pounds 9     ounces 

Keeping  the  child  on  an  exclusive  milk  diet  until  he  is  twelve 
months  of  age,  or  older,  is  a  not  infrequent  error.  As  a  rule,  starch  in 
some  form  may  be  added  to  the  food  at  the  seventh  month,  and  should 
always  be  added  as  early  as  the  ninth  month.  The  giving  of  food 
other  than  well-cooked  cereals  and  milk  before  the  twelfth  month  is  a 
mistake  made  in  many  households,  and  a  common  error  from  the 
twelfth  month  to  the  third  year  is  to  allow  the  child's  diet  to  con- 
sist largely  of  milk  and  insufficiently  cooked  cereals.  Crackers  and 
milk,  bread  and  milk,  with  cake  and  fancy  crackers,  often  constitute 
the  only  articles  of  diet  during  this  very  important  period  of  growth. 
The  fact  that  a  high  proteid  food  is  as  necessary  for  proper  develop- 
ment now  as  for  the  bottle  age,  is  overlooked.  During  early  infancy, 
milk  answered  well,  but  it  is  not  sufficient  for  the  demands  of  older 
childhood.  Milk,  eggs,  meat,  and  cereals,  such  as  oatmeal,  rich  in 
proteid,  are  absolutely  necessary  to  normal  growth. 

Irregularity  in  feeding  is  another  frequent  error.  The  child 
should  have  his  meals  "on  the  minute,"  at  the  same  time  every  day. 
The  lack  of  observance  of  this  rule  will  surely  result  in  loss  of  appetite 
and  indigestion.  Indiscriminate  eating  between  meals,  whether 
bread  and  butter,  or  pastry,  or  confectionery,  if  persistently  practised, 
will  surely  be  followed  by  indigestion  and  malnutrition. 

Forcing  or  coaxing  a  child  to  eat  is  a  practice  always  to  be 
avoided.  If  suitable  food  is  given  at  definite  well-ordered  intervals, 
a  normal  child  will  be  hungry  at  those  intervals.  If  he  does  not  eat, 
something  is  wrong,  and  it  is  our  duty  to  discover  the  cause  of  his 
loss  of  appetite. 

DIET  FROM  THE  FIRST  TO  THE  SIXTH  YEAR 

At  the  completion  of  the  twelfth  month  the  average  well-regulated 
breast  baby  should  be  weaned,  and  other  nourishment  given.  If 
bottle-fed,  he  should  receive  more  than  the  milk  and  cereals  which 
are  given  to  most  children.  The  food  suitable  for  the  second  year 
of  life,  and  the  method  of  its  preparation  and  administration,  are 
subjects  upon  which  the  masses  are  most  profoundly  ignorant.  A 
few  children  at  this  period  of  life  are  underfed,  but  the  great  majority 
are  overfed,  the  food  being  whollv  unsuitable,  wretchedly  cooked,  and 


DIET    FROM    THE    FIRST   TO    THE    SIXTH    YEAR 


129 


carelessly  given  at  improper  intervals.  vSummer  diarrhea  finds  its 
greatest  number  of  victims  among  such  children. 

The  Second  Summer. — The  dreaded  "second  summer"  robs  many 
homes  because  of  ignorant  or  careless  parents.  The  second  summer, 
properly  managed,  is  hardly  more  dangerous  than  any  other  summer 
during  the  early  years  of  a  child's  life.  It  is  almost  a  universal 
custom,  when  a  child  is  weaned  or  given  something  other  than  a 
milk  diet,  to  allow  him  "tastes"  from  the  table.  Very  often  these 
"tastes"  comprise  the  entire  dietary  of  the  adult.  Milk  is  often  the 
only  suitable  article  of  diet  that  is  given.  Afterward  not  only  is 
the  other  food  selected  unsuitable,  but  it  is  given  irregularly,  and 
supplemented  by  crackers  kept  on  hand  for  use  between  meab. 
During  the  hot  months  the  gastro-enteric  tract  is  less  able  than  at 
other  times  to  bear  such  abuse,  and  the  child  becomes  ill. 

Feeding  After  the  First  Year. — Usually,  when  the  twelfth  month 
is  completed,  I  give  the  mother  a  diet  schedule,  with  instructions  to 
begin  gradually  with  the  articles  allowed  in  order  to  test  the  child's 
ability  to  digest  them.  Every  new  article  of  food  should  be  care- 
fully prepared  and  given,  at  first,  in  very  small  quantities.  All  meals 
should  be  given  regularly,  with  nothing  but  water  between.  With 
many  children  this  expansion  of  the  diet  list  is  attended  with  con- 
siderable difficulty.  They  are  thoroughly  satisfied  with  the  milk, 
and  refuse  all  other  nourishment.  In  such  cases  time  and  patience 
are  necessary  at  the  feeding-time.  The  more  solid  articles  of  diet 
should  first  be  given,  and  the  milk  kept  in  the  background.  Among 
the  underfed  seen  at  this  period  of  life  are  those  who  were  nursed 
too  long,  or  those  who  were  kept  for  too  long  a  time  upon  an  exclusive 
milk  diet.  A  great  majority  of  the  cases  of  malnutrition  of  the 
second  year  are  seen  in  the  exclusively  milk-fed.  They  are  pale, 
soft,  flabby,  badly  nourished  children. 

The  following  is  a  diet  schedule  which  I  have  emploved  for 
several  years.  Each  mother  is  instructed  to  select,  from  the  articles 
of  food  allowed,  a  suitable  meal: 

From  ike  twelfth  to  the  fifteenth  month:  five  meals  daily. 

7  A.  M.  Oatmeal,  barley  or  wheat  jelly,  one  to  two  tablespoon- 
fuls,  in  eight  ounces  of  milk.  (The  jelly  is  made  by  cooking  the 
cereal  used  for  three  hours  the  day  laefore  it  is  wanted  and  then 
straining  through  a  colander.) 

9  A.  M.     The  juice  of  an  orange. 

II  A.  M.  vScraped  rare  beef,  mixed  with  an  equal  quantity  of 
bread-crumbs,  moistened  with  beef-juice,  one  to  three  teaspoonfuls. 
Or  a  soft-boiled  egg  mixed  with  stale  bread-crumbs,  a  piece  of  zwie- 
back, and  a  half-pint  of  milk. 

(Scraped  beef  is  best  obtained  from  round  steak,  cut  thick  and 
hroiled  over  a  brisk  fire  sufficiently  to  sear  the  outside.  The  steak 
9 


130  NUTRITION    AND    GROWTH 

is   then   split  with   a   sharp  knife  and  the   pulp  scraped  from   the 
fiber.) 

3  p.  M.  Beef,  chicken,  or  mutton  broth  with  stale  bread  broken 
into  it.'    Six  ounces  of  milk,  if  wanted. 

6  P.  M.  Two  tablespoonfuls  of  cereal  jelly  in  eight  ounces  of 
milk;  a  piece  of  zwieback. 

9.30  p.  M.     A  tablespoonful  of  cereal  jelly  in  eight  ounces  of  milk. 

From  the  fifteentli  to  the  eighteenth  mo)ith:  four  meals  daily. 

7  A.  M.  Oatmeal,  barley,  or  wheat  jelly,  one  to  two  tablespoon- 
fuls in  eight  ounces  of  milk.  (The  jelly  is  ,to  be  made  by  cooking 
the  cereal  used  for  three  hours,  and  straining  through  a  colander.) 

9  A.  M.     The  juice  of  one  orange. 

II  A.  M.  A  soft-boiled  Qgg  mixed  with  stale  bread-crumbs  or 
one  tablespoonful  of  scraped  beef  mixed  with  stale  bread-crumbs 
and  moistened  with  beef -juice.  A  drink  of  milk;  zwieback  or  bran 
biscuit,  or  a  crust  of  bread. 

3  p.  M.  Mutton,  chicken,  or  beef  broth,  with  stale  bread 
broken  into  it.  Custard,  cornstarch,  or  plain  rice  pudding,  stewed 
prunes,  baked  apple,  or  apple  sauce. 

6  P.  M.  Two  or  three  tablespoonfuls  of  cereal  jelly  with  eight 
to  ten  ounces  of  milk.     Zwieback  or  stale  bread  with  butter. 

From  the  eighteenth  to  the  twenty-fourth  month:  four  meals  daily. 

7  A.  M.  A  soft-boiled  egg  every  two  or  three  days,  farina 
(cooked  one  hour),  hominy  or  oatmeal  (each  cooked  three  hours), 
with  equal  parts  of  milk  and  cream  and  a  little  sugar.  A  drink  of 
milk,  bran  biscuit  and  butter,  or  stale  bread  and  butter. 

9  A.  M.     The  juice  of  one  orange. 

II  A.M.  Rare  beef,  minced  or  scraped,  the  heart  of  a  lamb 
chop  finely  cut,  spinach,  asparagus  tops,  strained  stewed  tomatoes, 
mashed  cauliflower,  baked  apple  or  apple  sauce.  A  drink  of  milk, 
stale  bread  and  butter. 

After  the  twenty-first  month,  baked  potato  and  well-cooked  string- 
beans  may  be  given. 

3  p.  M.  Chicken,  beef,  or  mutton  broth,  with  stale  bread  broken 
into  it,  custard,  cornstarch,  or  plain  rice  pudding,  stewed  prunes, 
a  drink  of  milk,  bran  biscuit  and  butter,  or  stale  bread  and  butter. 

6  p.  M.  Rice  (cooked  three  hours)  and  milk,  hominy  (cooked 
three  hours)  and  milk,  farina  (cooked  one  hour)  and  milk,  or  stale 
bread  and  milk. 

From  the  second  to  the  third  year:  three  meals  daily. 
Breakfast:   7  to  8  o'clock.     Wheatena,  oatmeal,  hominy,  cracked 
wheat   (each  cooked  three  hours),  with  equal   parts   of   milk  and 
cream  and  a  little  sugar. 


DIET  FROM    THE    FIRST    TO    THE    SIXTH    YEAR  131 

A  soft-boiled  egg  or  a  lamb  chop,  stale  bread  and  butter,  bran 
biscuit  and  butter;  a  drink  of  milk. 

At  ten  o'clock  the  juice  of  one  orange  may  be  given. 

Dinner:  12  o'clock.  Strained  soups  and  broths,  rare  steak, 
rare  roast  beef,  poultry,  fish,  baked  potato,  peas,  string  beans, 
mashed  cauliflower,  strained  stewed  tomatoes,  spinach,  asparagus 
tips,  bread  and  butter;  a  glass  of  milk.  For  dessert:  Plain  rice 
pudding,  plain  bread  pudding,  stewed  prunes,  baked  or  stewed  apple, 
junket,  custard  or  cornstarch. 

Supper:  5.30  to  6  o'clock.  Rice  and  milk,  farina  and  milk, 
bread  and  milk,  bread  and  butter,  or  bran  biscuit  and  butter. 
Twice  a  week,  custard  or  cornstarch  may  be  given  or  a  tablespoonful 
of  plain  vanilla  ice-cream. 

As  a  rule,  three  meals  answer  best  at  this  period.  With  three  meals 
a  child  has  a  better  appetite  and  much  better  digestion,  and  conse- 
quently thrives  far  better  than  one  whose  stomach  is  kept  constantly 
at  work.  Some  children,  however,  will  require  a  luncheon  at  3  or 
3.30  p.  M.,  and  will  not  do  well  without  it.  This  is  apt  to  be  the  case 
with  delicate  children,  particularly  those  under  two  and  one-half 
years  of  age.  If  food  is  necessary  at  this  hour,  a  glass  of  milk  and  a 
graham  biscuit,  or  a  cup  of  broth  and  zwieback  will  answer  every 
purpose.  Instead  of  the  afternoon  meal,  the  child  may  relish  a 
scraped  raw  apple  or  a  pear.  The  fruit  at  this  time  is  particularly 
to  be  advised  if  there  is  constipation.  Children  recovering  from 
serious  illness  will  require  more  frequent  feeding. 

From  the  third  to  the  sixth  year. 

Breakfast:  Cracked  wheat,  wheatena,  hominy,  oatmeal  (each 
cooked  three  hours).  These  may  be  served  with  equal  parts  of 
milk  and  cream  and  a  little  sugar. 

A  soft-boiled  Qgg,  omelet,  scrambled  Qgg,  chop,  bread  and  butter, 
bran  biscuit  and  butter,  a  glass  of  milk,  one  orange,  one-half  dozen 
stewed  prunes. 

Dinner:  Plain  soups,  rare  roast  beef,  beefsteak,  poultry,  fish, 
potatoes  stewed  with  milk  or  baked.  Peas,  beans,  strained  stewed 
tomatoes,  mashed  cauliflower,  spinach,  asparagus  tips,  bread  and 
butter,  a  cup  of  milk.  For  dessert:  Rice  pudding,  plain  bread 
pudding,  custard,  tapioca  pudding,  stewed  prunes,  stewed  apples, 
baked  apples  with  cream,  raw  apples,  pears  and  cherries. 

Supper:  Rice  and  milk,  farina  and  milk  bread  and  milk,  scram- 
bled Cigg  twice  a  week,  custard  or  cornstarch,  each  once  a  week, 
ice-cream  once  a  week,  bread  and  butter,  a  glass  of  milk. 

When  the  child  has  eggs  for  breakfast,  they  should  not  be  re- 
peated in  any  form  for  supper.  Red  meat  should  be  given  but  once 
a  day.  W^hen  the  child  has  a  chop  for  breakfast,  he  should  have 
poultry  or  fish  for  dinner.     At  this  age  of  great  activity  and  rapid 


132  NUTRITION    AND   GROWTH 

growth,  the  child  will  demand  food  between  dinner  and  supper. 
Carefully  selected  fruit,  such  as  an  apple,  a  pear,  or  a  peach,  may  be 
given  at  this  time,  supplemented  by  a  graham  cracker  or  two,  or  by 
stale  bread  and  butter,  if  it  is  found  that  their  use  does  not  interfere 
with  the  evening  meal. 

DIET  AFTER  THE  SIXTH  YEAR 
When  the  normal  child  has  passed  the  sixth  year  the  diet  may 
be  considerably  expanded,  approximating  to  that  of  the  adult  in 
variety;  certain  restrictions,  however,  are  to  be  borne  in  mind. 
Fried  foods  should  not  be  given,  highly  seasoned  dishes,  such  as  pie, 
rich  puddings,  gravies,  and  sauces,  are  to  be  avoided.  Salads  with 
plain  dressing  may  now  be  given.  Wine  and  beer,  coffee,  and  tea 
should  never  be  given  to  children  as  a  beverage.  A  point  to  be 
kept  in  mind  in  feeding  children  of  this  age,  as  well  as  those  who 
are  younger,  is  the  proper  cooking  of  vegetables.  Everything  in 
the  line  of  green  vegetables  should  be  cooked  until  it  can  readily  be 
mashed  with  a  fork. 

HOW  THE  CHILD  SHOULD  BE  FED 

In  the  foregoing  articles  on  feeding  I  have  endeavored  to  explain 
the  nature  of  the  food  required  by  the  growing  child,  and  the  inter- 
vals at  which  food  should  be  given.  This,  however,  does  not  entirely 
cover  the  subject.  A  child  should  never  dine  with  adults  until  he 
can  have  adult  diet,  if  the  circumstances  of  the  family  permit  him 
to  dine  alone  or  with  other  children.  It  is  a  refinement  of  cruelty 
to  expect  a  hungry  child  of  tender  age  to  sit  at  the  table,  see  and 
smell  the  fragrant  dishes,  and  be  forced  to  content  himself  without 
complaint  with  his  restricted  fare.  I  recall  this  custom  as  a  cause  of 
many  tears,  disputes,  and  fistic  encounters  with  attendants,  which 
formed  no  small  part  of  the  daily  routine  of  my  own  early  life. 

In  feeding,  the  spoon  or  fork  must  come  in  contact  only  with  the 
food  and  the  child's  mouth.  If  it  falls  to  the  floor  by  accident  it 
should  be  dipped  into  boiling  water  before  using  it.  Under  no 
circumstances  should  a  feeding  utensil  be  allowed  to  come  in  contact 
with  the  lips  of  the  nurse  or  mother.  Time  and  again  I  have  seen 
mothers  and  nurses  sip  or  swallow  the  first  teaspoonful  of  the  food 
which  is  to  be  given,  to  determine  if  it  is  of  the  proper  temperature, 
using  the  spoon  to  feed  the  child  immediately  thereafter.  At  other 
times,  when  the  food  is  not  particularly  attractive  to  the  child,  she 
will  place  the  spoon  in  her  own  mouth  as  though  intending  to  take 
it  herself.  Or  she  will  remove  from  the  spoon,  with  her  own  lips 
adhering  particles  of  food.  There  are  few  more  reprehensible  prac- 
tices than  the  foregoing,  and  if  parents  knew  the  dangers  to  which 
their  children  were  thus  subjected  they  would  not  for  one  instant 
tolerate  them.     Any  one  of  the  many  forms  of  pathogenic  bacteria 


DIET   DURING    ILLNKSS  1 33 

may  thus  be  readily  transferred  to  the  mouth  of  the  child.  It 
is  unquestionably  a  means  of  infection  with  tuberculosis,  diphtheria, 
and  syphilis".  The  germs  of  tuberculosis  and  diphtheria  are  fre- 
quently found  in  the  mouths  of  perfectly  healthy  adults.  They 
cause  no  symptoms  of  disease  because  of  the  normal  power  of  resis- 
tance of  such  adults.  The  resisting  powers  of  the  child,  however, 
to  these  microorganisms  are  very  slight,  and  when  these  germs  are 
carried  to  the  delicate  mucous  membrane  of  the  infant's  mouth  and 
throat  they  thrive  actively,  the  child  develops  diphtheria  or  tuber- 
culosis, and  the  family  grieves  and  wonders  how  the  child  could  ever 
have  contracted  the  disease. 

DIET  DURING  ILLNESS 

The  digestive  capacity  of  every  child  is  diminished  during  illness, 
depending  largely  upon  the  age  of  the  child  and  the  severity  of  the 
disease.  The  younger  the  child,  the  greater  the  incapacity.  This 
is  fairly  constant  with  all  the  ailments  of  childhood,  including,  of 
course,  those  which  directly  afifect  the  gastro-enteric  tract. 

Reduction  in  Food  Strength. — In  a  moderately  severe  bronchitis, 
wath  a  degree  or  two  of  fever,  the  digestive  capacity  is  slightl}^  dimin- 
ished and  a  25  percent  reduction  in  the  strength  of  the  food  wdll 
answer.  During  the  critical  stage  of  a  lobar  pneumonia  the  digestive 
powers  are  held  in  abeyance  and  predigested  foods  and  alcohol  must 
sustain  the  patient.  During  an  attack  of  measles,  scarlet  fever,  bron- 
chopneumonia, or  diphtheria  in  bottle-fed  infants,  at  the  height  of  the 
disease,  it  is  my  custom  to  reduce  the  strength  of  the  food  one-half  by 
the  addition  of  water,  to  make  up  for  the  quantity  removed.  For  ail- 
ments of  lesser  severity,  such  as  bronchitis,  with  a  temperature  of  100° 
to  101°  F.,  or  chicken-pox,  or  mild  measles,  I  reduce  the  strength  of  the 
food  from  one-fourth  to  one-third.  In  any  mild  ailment  or  injury 
which  confines  a  child  to  its  bed,  the  food  strength  should  be  cut 
down,  for  inactivity  as  well  as  disease  lessens  the  digestive  capacity. 

Among  nurslings  and  the  bottle-fed  these  precautions  are  partic- 
ularl}^  necessary.  A  child  with  fever  is  apt  to  be  thirsty  and  to  take 
more  food  than  in  health.  This  is  frequently  the  case  in  summer 
diarrhea.  In  order  to  avoid  this  taking  of  too  much  food,  I  not  only 
order  the  milk  to  be  diluted  for  the  bottle-fed,  but  I  instruct  the 
mothers  of  nurslings  to  give  a  drink  of  water  immediately  before  each 
nursing  and  between  nursings,  and  then  to  allow  the  child  to  nurse 
only  one-half  or  two-thirds  the  usual  time.  For  the  bottle-fed, 
one-half  to  two-thirds  of  the  contents  of  each  bottle  is  removed  and 
the  quantity  replaced  by  boiled  water,  so  that  the  amount  of  fluid 
given  remains  the  same. 

If  a  child  is  a  "runabout,"  over  two  years  of  age,  he  is  given  broths 
and  thin  gruel — one-half  milk  and  one-half  gruel.  By  carefully  watch- 
ing the  stools,  thus  fitting  the  food  to  the  child's  capacity,  we  will 


134  NUTRITION    AND    GROWTH 

avoid  grave  intestinal  complications  which,  during  the  summer,  often 
prove  to  be  more  serious  than  the  original  ailment.  In  the  acute  gastro- 
enteric troubles,  and  in  typhoid  fever,  all  milk  must  be  discontinued. 

The  dietetic  management  of  the  acute  intestinal  diseases  and 
typhoid  fever  is  referred  to  in  detail  under  their  respective  headings. 

The  Art  of  Feeding  in  Illness. — Not  only  is  food  oftentimes  taken 
in  insufficient  quantity  in  illness,  but  in  many  cases  it  is  absolutely 
refused.  In  other  cases,  during  coma  and  asthenic  states,  swallowing 
is  impossible.  In  delirium  and  in  conditions  of  collapse  nourish- 
ment must  be  given,  and  when  this  is  impossible  by  the  natural 
method,  we  have,  as  temporary  substitutes,  gavage,  oil  inunctions, 
and  rectal  feeding — all  referred  to  elsewhere. 

Forcing  the  child  to  take  nourishment  by  the  mouth  is  rarely 
necessary.  Coaxing  and  bribing  ordinarily  succeed  far  better. 
For  a  child  from  three  to  five  years  of  age  a  bright  new  penny  pos- 
sesses much  persuasive  power.  The  child  will  usually  take  its  food 
better  from  those  to  whom  it  is  accustomed,  like  the  mother  or 
nursery  maid.  The  trained  nurse  should  understand  that  while 
unacquainted  with  the  patient,  the  simpler  requirements  of  the 
child  are  to  be  looked  after  by  others  to  whom  the  patient  is  accus- 
tomed. 

The  nourishment  should  be  as  palatable  as  possible  and  serv^ed 
in  bowls,  cups,  or  plates  that  are  attractive  to  the  patient,  be- 
cause of  color,  pictures,  or  peculiarities  of  shape.  Junket,  flavored 
with  vanilla,  serv^ed  cold  is  a  favorite  food  for  sick  children  of  the 
"runabout"  age.  Frozen  custard  and  home-made  ice-cream,  made 
with  one-third  cream  and  two-thirds  milk,  will  usually  be  well  taken. 
Toast,  dry  bread,  and  crackers  made  in  peculiar  shapes  are  attractive 
to  the  child.  In  not  a  few  cases  I  have  succeeded  in  feeding  satis- 
factorily children  two  or  three  years  old,  when  several  other  schemes 
had  failed,  by  allowing  the  temporary  return  to  the  bottle,  from 
which  they  had  been  weaned  for  a  year  or  so. 

In  these  difficult  feeding  cases  the  child's  peculiarities  and  wishes 
must  be  studied.  Children  in  illness  require  water.  Oftentimes 
they  take  it  in  insufficient  quantities.  Those  who  refuse  plain 
water  will  often  take  ginger  ale,  sarsaparilla,  or  vichy.  In  the  event 
of  these  drinks  being  well  taken,  they  may  be  given  freely.  In  the 
acute  infectious  diseases,  which  include  pneumonia,  free  water- 
drinking  is  a  therapeutic  measure  of  no  mean  value. 

GAVAGE 
Gavage,  or  forced  feeding,  is  the  introduction  of  nourishment 
into  a  child's  stomach  by  means  of  a  tube  (Fig.  i6).  The  tubes 
are  to  be  obtained  at  the  instrument-makers  and  are  known  as 
"stomach-tubes  for  children,"  or  the  physician  can  make  one  himself 
at   a   small  cost.     All  that   is  required   is  a   soft-rubber  catheter, 


GAVAGE 


135 


American  No.  12,  a  one-eighth  inch  glass  tube  two  inches  long,  two 
feet  of  one-quarter  inch  plain  rubber  tubing,  and  a  small  glass  funnel. 
An  extra  opening  should  be  cut  in  the  catheter  about  one-half  inch 
from  the  original  one.  This  allows  a  more  rapid  introduction  of 
the  nourishment.  The  opening  can  very  easily  be  made  with  a 
small  pair  of  curved  scissors. 

In  Obstinate  Vomiting. — Gavage,  or  forced  feeding,  will  be  found 
useful  in  three  types  of  cases.  First,  as  a  means  of  feeding  in  obsti- 
nate vomiting.  vSeveral  years  ago,  when  the  writer  was  resident 
physician  at  the  New  York 
Infant  Asylum,  a  series  of 
observations  were  made  on 
cases  of  persistent  vomiting 
which  could  not  be  con- 
trolled by  stomach-washing 
or  the  ordinary  means  of 
treatment.  It  was  found 
that  patients  who  could  not 
retain  a  teaspoonful  of 
water  when  administered 
by  a  spoon  or  a  bottle  would 
retain  from  one-half  ounce 
to  one  ounce  of  water  when 
given  through  a  tube.  The 
same  child  who  vomited 
one  teaspoonful  of  milk 
or  other  food  would  re- 
tain this  amount  and  a 
great  deal  more  when  the 
food  was  given  by  the 
tube.  This  discovery  led 
to  more  extended  observa- 
tions. Twenty  cases  of 
persistent  vomiting  in  all 
were  treated  in  this  way, 
of  which  eighteen  were  re- 
lieved. This  series  of  ob- 
servations was  the  first  made  relating  to  the  use  of  gavage  or  forced 
feeding  in  persistent  vomiting.^ 

The  tube  which  is  to  be  passed  into  the  stomach  should  never  be 
oiled,  but  merely  dipped  into  the  solution  that  is  to  be  used.  It  is 
then  passed  in  rapidly  with  the  funnel  empty  and  the  nourishment 
immediately  poured  into  the  funnel.  When  the  food  has  passed 
into  the  stomach,  the  tube  should  be  compressed  and  quickly  with- 

'Kerley:  "Gavage  in  Persistent  Vomiting  in  Infants,"  Archives  of  Pediat- 
rics, Feb..  1901. 


Fig.  16.— Stomach-tube. 


136 


NUTRITION    AND   GROWTH 


drawn,  as  some  of  the  liquid  will  be  retained  in  the  tube  if  it  is 
withdrawn  slowly.  If  this  is  done  without  compressing  the  tube, 
an  escape  of  food  into  the  larynx  may  take  place  during  the  with- 
drawal of  the  tube  and  cause  choking,  coughing,  and  perhaps  vomit- 
ing. The  food  selected  should  be  thin  dextrinized  gruels,  or  broths 
and  gruels  combined,  which  have  answered  well  in  some  cases. 
When  used  for  the  obstinate  vomiting  cases,  it  is  well  to  use  gavage 
only  once  every  four  or  six  hours,  with  from  one-third  to  one-half 


Fig.  17.— Feeding  by  Gavage. 


the  quantity  of  food  given  in  health.  In  a  severe  illness,  such  as 
diphtheria,  pneumonia,  and  the  grave  intestinal  diseases,  gavage 
may  save  the  life  of  the  patient.  Not  infrequently,  in  such  cases, 
insufficient  nourishment  is  taken  to  support  life.  Rectal  feeding 
is  usually  of  value  only  for  a  day  or  two,  as  children  soon  become 
intolerant  of  it.  In  such  circumstances,  gavage  may  be  employed 
advantageouslv  for  several  davs  at  a  time.  In  fact,  it  is  the  only  way 
by  which  the  child  can  be  properly  nourished. 


gavage;  137 

The  position  of  llic  child  for  gavage  may  be  the  same  as  for 
stomach-washing,  or  the  child  may  rest  on  his  back  (I'ig.  17).  It  is 
well  to  clear  out  the  stomach  with  warm  water  before  each  feeding. 
In  children  without  teeth  the  bare  index-finger  is  all  that  is  necessary 
to  keep  the  mouth  open.  In  children  with  teeth  the  Denhard  gag 
of  the  O'Dwyer  intubation  set  (page  311)  should  be  used.  Pre- 
digested  cereal  foods,  completely  peptonized  milk,  and  stimulants 
well  diluted  may  be  given.  Usually  these  patients  badly  need  water. 
If  there  is  no  tendency  to  vomiting,  a  large  quantity  of  water  may 
be  given  with  the  nourishment  selected,  so  that  they  may  get  as 
much  liquid  as  they  are  accustomed  to  in  health.  Gavage  is  also 
most  useful  in  cases  of  extreme  malnutrition  and  exhaustion  or  in 
those  under  alcohol  or  opium  narcosis.  Infants  suffering  from  an 
extreme  degree  of  malnutrition  and  exhaustion  are  often  admitted 
into  a  hospital ;  and  occasionally  they  are  seen  in  private  practice. 
The  children  are  so  reduced  in  strength  that  not  enough  energy 
remains  for  the  taking  of  nourishment.  In  these  cases  gavage  is 
distinctly  a  life-saving  measure.  The  food  should  be  predigested 
cereals,  peptonized  milk,  or  one  of  the  various  peptone  preparations, 
given  in  quantities  suitable  to  the  age  of  the  child.  For  a  child  four 
months  of  age,  from  two  to  four  ounces  of  peptonized  milk  may  be 
given  every  two  hours.  Before  the  next  feeding  it  is  well  to  intro- 
duce a  few  ounces  of  water  and  withdraw  it  to  see  if  the  food  has  been 
properly  digested.  By  this  means  of  feeding  there  will  be  noticed, 
if  the  vitality  is  not  at  too  low  an  ebb  at  the  commencement,  a  daily- 
increase  in  strength  and  vigor,  which  proves  that  the  powders  of 
assimilation  persist  after  the  desire  for  food  or  the  child's  ability  to 
swallow  it  has  passed.  This  proves  that  we  must  never  regard  such 
a  case  as  hopeless  so  long  as  the  child  is  breathing.  Time  and  again, 
after  a  few  days'  feeding  in  this  way,  the  child  will  take  the  food  from 
the  bottle  or  spoon.  Breast-milk,  if  it  can  be  obtained,  may  be 
given  by  gavage  as  successfully  as  can  predigested  cow's  milk. 
The  malted  foods  on  the  market  have  been  used  temporarily  with 
advantage,  for,  while  deficient  in  nutritive  value  for  the  well,  they 
afford  sufficient  nourishment  for  temporary  use  in  the  very  ill,  and 
are  easy  of  digestion. 

Illustrative  Case. — In  a  recent  case  seen  in  consultation,  the  pa- 
tient, three  months  old,  was  almost  moribund,  as  the  result  of  ex- 
treme malnutrition.  The  temperature  ranged  from  94°  F.  to  96°  F. 
for  several  days.  No  food  could  be  taken.  A  wet-nurse  was  secured, 
but  the  child  would  not  nurse.  He  was  pale,  apathetic,  and  too  w^eak 
to  cry.  The  wet-nurse's  milk  was  drawn  from  the  breast  and  spoon- 
feeding attempted,  but  swallow^ing  was  impossible.  One  and  one-half 
ounces  of  breast-milk  were  fed  bv  gavage,  but  this  proved  too  strong, 
and  the  child  promptly  vomited  it.  It  was  then  diluted  one-half 
with  weak  barley-water.     At  first  one  ounce  was  given  at  a  feeding,. 


138  NUTRITION    AND    GROWTH 

which  was  gradually  increased  to  two  ounces,  all  being  retained  and 
digested.  In  a  week  the  child  was  able  to  nurse,  and  made  a  com- 
plete recovery,  weighing,  when  seven  months  of  age,  fourteen  pounds. 
At  the  time  gavage  was  commenced,  it  weighed  but  five  pounds. 

SUBSTITUTES  FOR  STOMACH-FEEDING 

In  the  management  of  the  diseases  of  children  conditions  arise 
from  time  to  time  which  necessitate  the  nourishment  of  the  patient 
by  channels  other  than  the  stomach.  In  persistent  vomiting,  when 
there  is  an  acute  involvement  of  the  stomach,  as  in  an  acute  gastro- 
enteric infection,  or  when  the  vomiting  is  due  to  some  more 
remote  cause,  as  in  meningitis  or  nephritis,  or  where  the  attack  is 
one  of  cyclic  vomiting;  and,  in  short,  whatever  be  the  cause,  the 
patient  must  receive  water  and  food  in  order  to  sustain  the  system 
until  the  exciting  factor  is  removed. 

Nutrition  by  means  other  than  the  stomach  may  be  necessary 
in  retropharyngeal  adenitis  or  abscess,  in  stricture  of  the  esophagus, 
in  diphtheria,  in  the  exanthemata,  and  in  pneumonia  during  the 
course  of  active  delirium.  A  substitute  for  stomach-feeding  is  often 
useful  in  marasmus,  in  the  generally  delicate,  and  in  those  with 
reduced  assimilative  powers.  Various  means  of  substitute  feeding 
have  been  attempted  from  time  to  time.  Nutritive  suppositories 
have  been  advocated  and  proved  failures,  perhaps  because  of  our 
inabilitv  to  place  them  sufficiently  high  in  the  bowel.  Placed  in  the 
rectum,  they  excite  peristalsis  and  are  expelled. 

Hypodermic  Feeding. — Hypodermic  feeding,  and  the  introduction 
of  food  into  the  circulation,  in  children  are  unsafe  and  impracticable. 

Feeding  by  Inunction. — Feeding  by  means  of  oil  inunctions,  by 
active  friction,  or  by  the  more  passive  means  of  wrapping  the 
child  in  oil-soaked  cotton  and  allowing  him  to  rest  in  it,  is  thought 
by  many  to  be  effective,  in  spite  of  the  fact  that  the  skin  is  an  organ 
of  excretion,  and  that  its  powers  of  absorption  are  very  slight.  I 
am  convinced  that,  for  infants  and  young  children,  the  inunctions  of 
properly  selected  oils  possess  distinct  nutritive  value,  more  benefit 
being  derived  by  the  patient  than  can  be  attributed  to  the  lubrication 
of  the  skin  and  the  massage.  The  rubbing  of  mercurial  ointment  into 
the  skin  is  one  of  the  most  familiar  means  of  introducing  mercury 
into  the  circulation.  No  one  will  dispute  the  efficacy  of  this  form 
of  treatment.  Fat  inunctions  are  useful  in  marantic  infants,  and  in 
delicate  "runabouts"  with  low,  fat-digestive  capacity.  In  chronic 
diseases  also,  such  as  tuberculosis,  syphilis,  and  rheumatism,  oil 
inunctions  are  of  advantage.  They  may  be  used  with  service  during 
convalescence  from  the  severe  acute  diseases  which  have  not  only 
reduced  the  patient's  weight,  but  have  so  affected  the  digestive  and 
assimilative  functions  that  a  return  to  health  is  materially  retarded. 
A  brine  bath   (page  31)    should  precede    the    inunctions,  both   of 


the;  delicatk  child 


143 


characteristics  in  common  that  they  constitute  a  class  themselves, 
and  as  such  warrant  our  attention. 

Normal  Development. — The  average  child,  at  the  various  periods 
of  early  life,  conforms  with  a  certain  degree  of  regularity  to  the  mental 
and  physical  development  which  by  long  association  we  have  come  to 
regard  as  normal.  Thus  a  standard  may  be  said  to  have  been  estab- 
lished, and  it  is  up  to  this  standard  that  we  expect  the  growing  child 
to  measure.  This  is  what  we  look  upon  as  the  average  of  physical 
and  mental  development.  A  few  children  exceed  these  requirements ; 
they  are  stronger  and  larger  at  the  sixth  month  than  the  average 
child  at  the  ninth  month.  Again,  older  children  at  the  fourth  or  fifth 
year  are  in  every  way  equal  to  their  normal  playmates  a  year  or 
two  older. 

Abnormal  Development. — On  the  other  hand,  there  are  children 
who  are  born  with  a  reduced  vitality,  or  who,  through  faulty  manage- 
ment, usually  in  relation  to  feeding,  acquire  a  reduced  vitality. 
vSemi-invalid  adults  almost  invariably  beget  semi-invalid  children. 
If  the  parents  are  of  average  health  and  of  good  habits,  and  the  de- 
bilitated condition  of  the  child  is  due  to  faulty  management  and 
nutritional  errors,  the  result  of  proper  dietetic  and  hygienic  manage- 
ment is  usually  prompt  and  satisfactory.  With  the  persistently  deli- 
cate, the  offspring  of  physically  enfeebled  parents,  the  results  are 
less  satisfactory. 

Treatment. — By  proper  regulation  of  the  habits  of  a  delicate 
child,  however,  as  regards  all  the  details  of  his  daily  life,  a  far  better 
adult  is  produced  than  if  no  such  effort  had  been  made.  In  other 
words,  a  diet  and  general  regime  of  life  best  adapted  to  the  individual 
in  question  will  invariably  improve  the  physical  condition  of  that  in- 
dividual. This  applies  to  the  strong  as  well  as  to  the  delicate,  ta 
the  growth  and  development  of  the  young  of  the  lower  animals  as 
well  as  to  the  offspring  of  man.  It  is  the  poorly  developed,  delicate 
child  that  we  are  particularly  to  consider — the  undersized,  frail, 
small-boned,  under-weight  child,  whose  appetite  is  persistentlv  poor 
or  capricious,  who  sleeps  poorly,  tires  easily,  is  usually  constipated, 
who  is  subject  to  catarrhal  conditions  of  the  respiratory  tract,  and 
whose  powers  of  resistance  generally  are  diminished. 

On  assuming  the  management  of  one  of  these  children  it  is 
absolutely  necessary  to  make  a  thorough  examination,  followed 
in  some  instances  by  a  few  weeks'  observation,  in  order  to  become 
acquainted  with  the  case  in  its  individual  aspects,  to  learn  idiosyn- 
crasies, and  to  eliminate  the  factor  of  actual  disease  as  a  causative 
agent.  When  we  demonstrate  to  our  satisfaction  that  the  child 
is  free  from  such  diseases  as  tuberculosis,  syphilis,  and  malaria; 
when  we  have  eliminated  by  properly  directed  treatment  all  causes, 
such  as  adenoids,  phimosis,  adherent  clitoris,  vaginitis,  or  parasitic 
and  irritant  skin  lesions,  which  may  have  had  a  deterrent  influence 


144 


NUTRITION    AND   GROWTH 


Upon  growth ;  and  when  we  have  satisfied  ourselves  as  to  the  actual 
condition  of  our  patient,  we  are  in  a  position  to  lay  down  definite 
rules  of  management. 

Every  child  has  a  distinct  function  to  perform.  As  soon  as  he 
is  born  he  is  confronted  with  a  serious  problem — the  problem  of 
growth,  physical  and  mental.  Inasmuch  as  this  growth  and  develop- 
ment depend,  above  all  things,  upon  a  properly  adapted  food-supply, 
it  must  be  our  first  step  to  provide  such  nutriment  as  will  be  most  con- 
ducive to  it.  As  growth  takes  place  in  all  parts  of  the  body  through 
cellular  activity,  the  nutritive  elements  which  support  cell  prolifera- 
tion must  be  important  constituents  of  the  diet,  and  among  these 
the  proteids  are  of  prime  importance ;  hence  in  the  management  of 
these  children  a  point  to  be  remembered  in  the  adaptation  of  the  food 
is  the  necessity  of  feeding  as  rich  a  proteid  as  the  child  can  assimi- 
late.    The  younger  the  child,  the  greater  the  necessity  for  growth. 

Regular  Weighings  Necessary. — An  infant  should  be  weighed  at 
regular  intervals,  and  if  under  one  year  of  age,  should  not  be  con- 
sidered as  doing  even  passably  well  if  not  gaining  at  least  four  ounces 
weekly.  When  a  baby  remains  stationary  in  weight  its  development 
is  invariably  abnormal.  When  stationary  or  when  only  a  slight  gain 
of  one  or  two  ounces  weekly  is  made,  we  will  always  find  after 
a  few  weeks  that  there  is  malnutrition,  in  spite  of  the  apparent 
gain,  as  will  be  evidenced  by  the  symptoms  of  beginning  rickets — 
anemia,  the  characteristic  bone  changes,  flabby  muscles,  and  a 
tendency  to  disease  of  the  mucous  membranes.  Delicate  infants 
should  be  weighed  daily  at  first;  then,  as  improvement  takes  place, 
at  inter\^als  of  two  or  more  days,  but  never  less  frequently  than  once 
a  week,  if  under  one  vear  of  age,  no  matter  how  vigorous  they  may 
become.  The  weighing  keeps  us  directly  in  touch  with  the  child's 
condition,  but  since  the  increase  may  be  in  fat  alone,  an  occasional 
examination  of  the  child  stripped  is  necessary  to  tell  us  whether 
there  is  substantial  growth  in  bone  and  muscle. 

Feeding  Infants. — When  it  is  demonstrated  that  a  child  will  not 
thrive  on  the  breast  of  the  mother,  another  breast  should  be  substi- 
tuted, or  an  adapted  high-proteid  cow's  milk  should  form  the  diet  in 
part  or  in  whole.  If  the  child  is  bottle-fed  and  it  is  demonstrated 
that  proper  growth  and  development  are  impossible  on  cow's  milk, 
on  account  of  proteid  incapacity,  then  a  wet-nurse  should  be  secured. 

When,  after  the  first  year,  more  liberal  feeding  is  allowed,  the 
necessity  for  a  high  proteid  in  the  food  selected  is  as  urgent  as  before. 
This  applies  to  those  children  who  are  brought  to  us  showing  evi- 
dences of  late  malnutrition,  as  well  as  to  those  whom  we  have  had 
under  our  care  from  early  infancy. 

An  important  element  in  the  diet  up  to  the  third  year  is  milk. 
A  child  from  the  first  to  the  third  year  ought  to  receive  one  quart  of 
milk  daily.     Unfortunately,  many  debilitated  children  have  a  very 


THE    DELICATE    CHILD  I45 

poor  capacity  for  fat  assimilation.  When  given  full  milk  in  as 
small  an  amount  as  one  pint  daily,  they  often  develop  foul  breath, 
coated  tongue,  and  loss  of  appetite,  or  they  suffer  from  frequent 
attacks  of  acute  indigestion.  The  milk  is  necessary,  not  because 
of  the  fat,  which  can  easily  be  dispensed  with,  but  because  of  the 
high  percentage  of  proteid  which  it  contains — from  3  to  4  percent. 
When  this  fat  incapacity  exists,  the  milk  is  said  to  "disagree,"  but 
skimmed  milk  will  be  taken  without  inconvenience.  Enough  sugar 
may  be  added  to  bring  the  percentage  up  to  seven,  in  order  that  it 
may  replace  the  fat,  for  fuel.  Skimmed  milk  with  sugar  added 
furnishes  a  food  of  no  mean  order.  Too  much  milk,  however, 
must  not  be  given.  When  large  quantities,  more  than  one  quart 
daily,  are  taken,  the  desire  for  more  substantial  nourishment,  such 
as  eggs,  meat,  and  cereals,  is  removed. 

At  the  completion  of  the  first  year,  keeping  in  mind  a  high 
proteid  (page  82),  begin  with  scraped  beef,  at  first  one  teaspoonful 
once  a  day.  in  addition  to  the  cereal  and  milk.  If  this  is  well  borne, 
and  it  usually  is,  a  teaspoonful  may  be  given  twice  a  day,  and  later 
three  times  a  day.  It  may  be  given  immediately  before  the  bottle- 
feeding.  Eggs  should  be  brought  into  use  from  the  twelfth  to  the 
fifteenth  month.  At  first  one-half  an  egg,  boiled  two  minutes,  is  given 
mixed  with  bread-crumbs.  If  well  borne,  a  whole  egg  may  be 
allowed.  The  cereals  used  should  be  those  most  rich  in  vegetable 
protein,  such  as  oatmeal,  containing  16  percent  of  proteid,  dried 
peas,  20  percent  of  proteid,  and  dried  beans,  containing  24  percent 
of  proteid.  The  peas,  beans,  and  lentils  should  be  given  in  the 
form  of  a  puree. 

Diet  after  the  First  Year. — If  the  child  after  the  second  year  has 
an  indifferent  appetite,  reduce  the  quantity  of  milk;  never  allow 
more  than  one  pint  of  skimmed  milk  daily  for  the  first  week  or 
two.  Many  delicate  children  who  apply  for  treatment  after  the  first 
year  of  age  have  been  subjected  to  as  grave  errors  in  diet  as  are  seen 
among  the  bottle-fed.  Starch  and  milk  oftentimes  furnish  the  only 
means  of  nutrition  up  to  the  fourth  or  fifth  year,  the  starch  used 
being  generally  in  the  form  of  bread,  crackers,  and  ill-cooked  cereals. 
In  one  case  four  quarts  of  milk  were  taken  daily  by  a  boy  of  seven 
years. 

It  will  be  seen  that  it  is  our  aim  in  this  class  of  children — the 
delicate,  undersized,  slow-growing  class — to  give  as  liberal  a  nitro- 
genous nourishment  as  is  compatible  with  the  digestive  capacity 
of  the  patient.  But  if  the  child  has  had  rheumatism,  or  if  there  is 
a  tendency  to  lithiasis,  the  use  of  a  large  amount  of  meat  is  con- 
traindicated.  It  is  in  such  children  that  the  high-proteid  cereals 
are  particularly  valuable.  In  a  general  way,  from  early  life  the 
diet  of  the  delicate  child  should  consist  of  milk,  suitably  adapted, 
with   highly   nitrogenous   cereals   added,  when  permissible.     Many 


146  NUTRITION    AND   GROWTH 

delicate  children  of  the  "runabout"  age  who  cannot  digest  milk 
containing  4  percent  of  fat  will  easily  digest  butter  fat  when  spread 
on  bread  or  potatoes.  In  this  way  I  often  use  it  to  supply  fuel  to 
act  as  a  proteid-sparer.  Oatmeal-water,  or  oatmeal  jelly,  mixed 
with  the  milk  should  be  ordered  at  the  seventh  month.  When  age 
allows,  the  addition  of  raw  or  rare  meat,  poultry,  eggs,  and  purees  of 
dried  peas,  beans,  and  lentils  should  be  given.  Boxed,  "ready  to 
serve"  cereals  are  never  given ;  raw  cereals  are  used,  which  are  cooked 
three  hours.  While  a  high-proteid  diet  is  desirable,  other  things 
are  necessary.  Green  vegetables,  animal  fats,  the  ordinary  cereals, 
cooked  and  raw  fruits,  are  required  to  furnish  the  necessary  acids 
and  salts,  as  well  as  the  necessary  variety.  In  short,  the  ideal  diet 
for  a  delicate  child  is  that  combination  of  foods  which,  while  imposing 
the  least  burden  upon  the  digestive  organs,  supplies  the  body  with 
material  exactly  sufficient  for  its  needs,  and  such  a  food  must  be 
rich  in  nitrogen.     (See  dietary,  page  128.) 

Baths. — On  account  of  the  fear  that  a  delicate  child  may  take  cold, 
the  bath  is  often  omitted.  Every  child,  both  the  well  and  the  deli- 
cate, after  the  second  week  should  be  tubbed  daily.  The  delicate 
particularly  require  it.  The  salt  bath  (page  31)  is  usually  advised. 
The  best  time  for  giving  the  bath  is  at  bedtime,  and  in  order  to 
avoid  all  chance  of  exposure  the  temperature  of  the  room  should  be 
elevated  to  80°  F.  The  temperature  of  the  water  may  vary.  It 
should  never  be  above  95°  F.  except  for  very  delicate  young  children 
in  whom  there  is  a  tendency  to  a  subnormal  temperature.  Even 
in  these  cases  the  temperature  of  the  bath  should  never  be  higher 
than  the  temperature  of  the  body.  In  the  frail  and  in  the  very 
young  the  bath  should  not  be  continued  over  five  minutes.  In 
older  children,  those  of  eighteen  months  or  over,  if  the  physical 
conditions  allow,  a  distinct  advantage  will  be  gained  by  a  reduction 
of  the  temperature  of  the  bath  while  the  child  is  in  the  water.  An 
immersion  in  water  at  90°  F.,  followed  by  a  gradual  reduction  during 
the  space  of  five  or  six  minutes  to  70°  F.,  should,  upon  brisk  rubbing, 
be  followed  by  a  quick  reaction.  For  children  after  the  third  year, 
a  graduated  cold  spinal  douche  has  served  me  well.  (See  Spinal 
Douche,  page  29.)  If  the  reaction  is  not  good,  if  the  extremities 
are  cold  and  are  slow  in  becoming  warm,  the  reduction  in  the  tem- 
perature should  be  less  or  none  at  all.  In  the  very  poorly  nourished, 
a  reduction  below  80°  F.  should  not  be  attempted.  Following  the 
drying  process,  primarily  for  the  benefit  of  the  massage,  goose  oil  or 
olive  oil  should  be  rubbed  into  the  skin  over  the  entire  body  for  from 
five  to  ten  minutes.  The  bath  and  the  massage  inunction,  besides 
favorably  influencing  nutrition,  are  a  very  effective  means  of  inducing 
sleep. 

Fresh  Air. — Delicate  children  are  usually  deprived  of  a  proper 
amount  of  fresh  air,  for  the  same  reason  that  they  are  insufiiciently 


THE    DEUCATE    CHILD  147 

bathed — the  fear  of  making  them  ill.  All  children  need  an  abundance 
of  fresh  air,  both  in  illness  and  in  health.  The  robust  and  the  delicate 
require  it,  and  to  the  delicate  it  is  much  more  essential  than  to  the 
robust.  As  many  hours  daily  as  practicable  should  be  spent  out  of 
doors.  The  time  thus  spent  depends  upon  the  season  of  the  year 
and  the  residence  of  the  child,  whether  in  the  city  or  the  country. 
In  the  city,  during  the  colder  months  with  pleasant  weather,  the 
child  should  spend  at  least  five  hours  daily  in  the  open  air,  dividing 
the  day  into  two  outing  periods — from  9  to  1 1.30  in  the  morning  and 
from  2  to  4.30  in  the  afternoon.  On  very  cold  days,  20°  F.  or  below, 
on  stormy  days,  and  on  days  with  very  high  winds,  the  child  is 
given  his  airing  indoors.  He  is  dressed  as  for  out  of  doors,  placed 
in  his  carriage,  and  left  in  a  room,  the  windows  on  one  side  of  the 
room  being  open.  Not  infrequently  during  February  and  March 
delicate  children  will  be  prevented  from  going  out  of  doors  for 
several  consecutive  days.  If  some  means  for  a  daily  systematic 
indoor  airing  is  not  provided,  these  children  will  often  go  backward, 
no  matter  how  excellent  the  other  management.  The  first  symptoms 
are  loss  of  appetite  and  the  ability  to  assimilate  the  food.  In  my 
private  work  among  athreptics,  the  child  is  placed  in  the  baby- 
carriage  or  in  a  basket  and  allowed  to  rest  before  an  open  window 
for  ten  or  twelve  hours  of  every  twenty-four,  with  a  hot-water 
bottle  at  his  feet.  Here  he  is  fed,  being  removed  only  temporarily 
to  warmer  quarters  for  a  change  of  napkins.  I  have  three  roof- 
gardens  in  operation.  A  boy  patient  nine  months  of  age  has  been 
in  the  street  only  once  in  four  months,  then  only  in  going  to  church 
to  be  baptized. 

Sleep. — The  delicate  child  requires  no  more  sleep  than  does  the 
strong,  and  the  rules  governing  this  matter  at  the  various  periods 
of  life  are  the  same  both  for  the  strong  and  for  the  weak,  (See 
Sleep,  page  27.)  The  sleeping- room  of  the  delicate  child  should 
always  communicate  with  the  open  air  by  a  window,  either  directly 
or  through  an  adjoining  room.  A  satisfactory  method  of  ventila- 
tion is  by  the  window-board  (page  43).  The  child  should  occupy 
the  room  alone,  if  possible,  sharing  it  neither  with  an  adult  nor 
another  child.  This  applies  to  all  ages,  but  is  particularly  necessary 
after  the  second  year. 

The  Nursery. — The  temperature  of  the  nursery,  day  or  night, 
should  never  be  above  70°  F.,  during  the  colder  months,  and  in  the 
very  young,  or  in  those  who  are  difficult  to  keep  covered,  it  should 
not  go  below  65°  F.  at  night. 

Delicate  children  of  the  "runabout"  age  are  very  susceptible 
to  colds.  In  the  management  of  such  children  it  is  necessary  to  use 
every  precaution  against  exposure.  The  most  frequent  way  of 
exposing  a  child  to  cold  is  bv  allowing  him  to  sit  on  the  floor.  To 
keep  the  child  of  from  ten  months  to  three  years  of  age  off  the  floor 


148  NUTRITION    AND   GROWTH 

during  the  winter  months,  and  thereby  to  eUminate  this  means  of 
exposure,  is  a  very  difficult  matter.  In  fact,  with  active  children 
learning  to  walk,  or  who  have  just  learned  to  walk,  it  is  practically 
impossible  under  the  usual  conditions.  During  the  colder  months 
there  is  always  a  current  of  cold  air  near  the  floor,  and  allowing  the 
child  to  creep  in  winter,  even  if  the  floor  is  protected  by  rugs  and 
carpets,  is  one  of  the  surest  ways  of  permitting  him  to  take  cold. 
If  he  is  allowed  to  walk  on  the  floor  he  is  soon  very  sure  to  sit  down. 
If  he  is  not  allowed  to  creep  and  walk  about  at  will,  he  will  not  get 
the  proper  exercise  and  will  show  faulty  development.  For  such 
cases,  I  have  found  the  exercise  pen  of  immense  service  (see  Fig.  4). 
After  being  dressed,  washed,  and  fed,  the  child  is  placed  in  the  pen, 
on  a  rug  if  desired.  Toys  are  given  him  and  the  door  is  closed.  He 
can  now  roam  about  at  will,  stand  up,  sit  down,  creep  or  walk  without 
the  slightest  danger  from  drafts. 

Influence  of  Climate. — Much  has  been  written  regarding  the  influ- 
ence of  climate  in  the  type  of  case  we  are  considering.  According  to 
my  observation,  this  matter  does  not  deserve  the  attention  it  has  re- 
ceived. The  city  child  in  a  well-to-do  family  is,  as  a  rule,  better  off 
for  eight  months  of  the  year  in  his  own  home  with  its  usual  conveni- 
ences. The  benefits  attributed  to  change  in  climate  are  usually  the 
result  of  a  change  not  of  climate  but  to  more  fresh  air,  which  is  af- 
forded by  the  larger  rooms  of  the  hotel,  with  its  loosely  constructed 
doors  and  windows ;  and  since  the  parent  is  desirous  that  the  child 
shall  receive  the  full  benefit  of  the  change,  he  is  kept  in  the  open  air 
for  a  much  longer  time  than  when  at  home.  The  air  at  such  a  place 
is  more  expensive,  and  consequently  more  appreciated  than  the  air 
at  home.  With  sufficient  heat  and  proper  ventilation,  we  may  make 
our  own  climate.  It  is  not  to  be  denied,  however,  that  a  change  of 
residence  for  a  few  weeks  from  New  York  to  Lakewood  or  Atlantic 
City  during  March  and  April  is  sometimes  of  advantage. 

From  the  first  of  June  to  the  first  of  October  the  delicate  child 
should  not  remain  in  New  York  city.  The  humidity  and  the  heat 
which  may  prevail  for  protracted  periods  during  this  time  render  it 
unsafe,  particularly  during  July  and  August.  The  seashore  for  the 
entire  summer  is  not  to  be  advised.  The  children  whom  I  have  sent 
inland  to  the  country  and  to  the  mountain  have,  as  a  rule,  returned 
in  the  autumn  in  a  much  better  physical  condition  than  those  who 
spent  the  summer  by  the  sea. 

Clothing. — Thin,  poorly  nourished  children  require  more  clothing 
than  do  those  physically  normal.  A  fairly  good  index  as  to  whether 
a  child  is  sufficiently  clad  is  the  condition  of  his  lower  extremities. 
The  forearm  and  hand  cannot  be  relied  upon.  The  legs  and  feet  of 
every  child  should  always  be  warm  to  the  touch. 

As  to  the  nature  of  the  clothing:  A  mixture  of  silk  and  wool 
next  to  the  skin  is  most  desirable.     As  a  second  choice  a  mixture  of 


THE    DELICATE   CHILD  1 49 

wool  and  cotton  is  used.  The  linen  mesh,  often  useful  in  the  vigo- 
rous "  runabout,"  is  not  to  be  advised  in  the  delicate. 

Exercise. — Moderate  exercise  is  to  be  encouraged.  But  it  should 
never  be  allowed  to  the  point  of  fatigue.  In  large  cities  all  delicate 
"  runabouts"  from  three  to  five  years  of  age  should  be  allowed  to  walk 
not  more  than  six  blocks  in  going  to  the  playgrounds.  If  the  distance 
is  greater,  the  child  should  ride  part  of  the  way,  play  or  walk  for  a 
time,  and  then  be  placed  in  the  carriage  or  cart  and  ride  home. 
Younger  children,  two  or  three  years  of  age,  should  be  wheeled  both 
ways  and  taken  out  at  the  park  for  a  run  when  the  weather  con- 
ditions permit. 

Midday  Nap. — Every  day  after  the  midday  meal  the  child,  regard- 
less of  age,  whether  two  years  or  six,  should  be  undressed  and  put 
to  bed  for  two  hours.  He  should  be  left  alone  in  the  room,  and 
whether  he  sleeps  or  not  he  should  remain  in  bed  for  the  two  hours. 

Entertainment. — Entertaining  play  is  necessary,  but  every  kind  of 
excitement,  such  as  children's  parties,  emotional  plays  at  the  theater, 
and  rough  play  with  older  children,  should  be  avoided. 

Education. — The  delicate  child  under  eight  years  of  age  should  be 
taught  only  to  the  extent  of  strict  obedience  and  good  habits.  Other 
than  this  he  should  be  a  little  animal.  There  should  be  no  teaching 
in  the  ordinary  sense  of  the  term,  no  mental  stimulation,  until  the 
child  is  physically  able  to  bear  it.  When  school-work  begins,  which 
in  this  class  of  children  should  never  be  before  the  eighth  year,  the 
studies  should  be  made  easy  and  the  school-hours  short.  Such  chil- 
dren should  never  be  crowded.  I  usually  direct  that  they  attend 
only  the  morning  session. 

The  delicate  child  should  be  carefully  watched  from  the  time  it 
comes  into  our  hands  until  it  reaches  the  normal  or  until  the  period 
of  development  is  completed.  While  the  scheme  of  management 
as  outlined  will  not  always  be  attended  with  brilliant  results,  it 
will  not  be  in  vain.  Many  lives  will  be  saved,  and  as  a  result  of 
the  increased  acquired  resistance,  stronger  men  and  women  will  be 
added  to  the  race  than  would  otherwise  have  been  possible. 

Now  and  then  I  meet  with  a  case  among  the  well-to-do  in  which, 
because  of  prolonged  faulty  feeding  or  vicious  heredity,  the  vital 
spark  is  so  low  that,  fan  it  as  we  may,  no  impression  is  made  upon  it. 
As  a  rule,  these  stubborn  cases  are  the  offspring  of  alcoholism  and 
debauchery.  They  are  thin,  anemic  infants;  thev  develop  into  thin, 
anemic  children,  and  into  thin,  anemic  adults.  The  delicate  and 
degenerate  are  found  in  all  the  walks  of  life,  but  they  are  especially 
numerous  in  dispensaries  and  in  children's  institutions. 

Much  of  the  work  of  the  pediatrist  is  with  the  weakly  of  the  so- 
called  "  better  class."  His  success  in  the  management  of  these 
delicate  children  depends  largely  upon  the  home  cooperation,  and  a 
promise   of   this   he    should    obtain   before   taking   the   case.     The 


I50  NUTRITION    AND   GROWTH 

parents  must  be  taught  that  the  development  of  the  intellect,  the 
character,  and  the  body  go  hand  in  hand,  and  that  a  vigorous  intel- 
lect is  rarely  found  without  a  vigorous  body.  It  is  impressed  upon 
them  that  the  body  is  more  than  a  machine.  It  has  delicate  organs 
to  hold,  to  keep  in  repair  and  supply  with  energy.  It  has  a  nervous 
organization;  it  has  sensibilities.  The  normal  exercise  of  all  these 
functions  demands  the  normal  nourishment  of  the  body.  In  my 
experience,  family  cooperation  in  a  few  instances  has  been  difficult  to 
obtain.  The  parents  began  well,  but  soon  tired  of  the  extra  work 
required.  The  care  of  the  young  has  always  been  undertaken  in  such 
a  wretched,  unscientific  manner  that  it  is  difficult  to  make  the  un- 
trained mind  appreciate  the  necessity  of  careful  attention  to  details 
in  his  management. 

The  Child  vs.  the  Animal. — It  is  a  startling  fact  that  75  percent  of 
all  children  do  not  get  as  scientific  care  and  attention,  as  regards  the 
selection  of  food,  housing,  and  exercise,  as  do  the  calves  and  colts,  the 
lambs  and  pigs,  of  any  high-class  stock-farm.  Is  this  because  the  child 
has  no  market  value  in  dollars  and  cents?  In  France,  during  the  past 
few  years,  this  defect  in  the  people  as  a  whole  has  received  govern- 
mental attention;  and  on  account  of  the  diminished  birth-rate,  the 
value  of  a  human  life  is  beginning  to  be  appreciated.  That  the  subject 
of  better  care  of  the  young  deserves  our  earnest  consideration  is  well 
illustrated  by  the  statement  recently  made  in  the  House  of  Commons, 
by  Sir  William  Anson,  Parliamentary  Secretary  of  the  Board  of  Edu- 
cators, that  sixty  thousand  children  of  those  attending  the  London 
schools  were  physically  unfit  for  instruction.  The  Adjutant-General 
of  the  English  Army  Medical  Service  reported  that  one  man  in  every 
three  offered  as  recruits  ought  to  be  rejected. 

The  two  bills  now  before  Congress  at  Washington,  relating  to 
the  formation  of  a  bureau  to  investigate  the  condition  of  children, 
shows  that  our  own  country  is  beginning  to  realize  a  long-felt  need. 

MARASMUS ;  ATHREPSIA ;  INFANTILE  ATROPHY 
Under  this  title  will  be  considered  those  cases  of  marasmus 
which  are  associated  with  and  dependent  upon  derangement  of 
function  of  the  gastro-enteric  tract.  Tuberculosis,  syphilis,  and 
atelectasis  are  consequently  excluded,  these  affections  being  con- 
sidered elsewhere  under  their  respective  headings. 

Marasmus  is  seen  most  frequently  in  young  infants  under  nine 
months  of  age.  Cases  are  frequently  seen,  however,  from  the  ninth 
to  the  twelfth  month,  and  comparatively  few  between  the  twelfth  and 
eighteenth  months.  A  great  deal  of  research  work  has  been  done 
in  marasmic  infants  in  order  to  determine  the  nature  of  the  condition, 
but  as  yet  no  satisfactory  explanation  has  been  offered.  The  disease 
is  unquestionably  due  to  defective  intestinal  assimilation.  The 
principal  fact  that  disproves  the  existence  of  any  atrophic  condition 


marasmus;    athrepsia;    infantile  atrophy  151 

or  any  necessarily  severe  derangement  of  function  is  that  these  cases 
very  often  make  complete  recoveries,  becoming  perfectly  normal 
children  after  six  months  of  treatment. 

The  story  of  these  cases,  which  we  have  heard  hundreds  of  times, 
both  in  out-patient  and  in  private  work,  is  about  as  follows:     The 
mother  could  not  or  did  not  nurse  the  baby.     The  child  was  put  on 
cow's   milk,   which  was    usually  given  too  strong  or  in  too  large 
quantities— oftentimes  both  errors  were  combined,  or  the  milk  may 
have  been  too  old  when  used   and   improperly  cared   for;    in  any 
case  the  milk  disagreed,  the  child  was  made  ill,  there  was  loss  in 
weight,  cow's  milk  was  discontinued,  and  one  of  the  infant  foods, 
alone  or  combined  with  milk,  was  given;  but,  the  child's  digestion 
being  thoroughly  disordered,  the  foods  failed  to  agree.     There  was 
vomiting  or   regurgitation   with   undigested   green   stools,   or  both 
combined,  while  the  loss  in  weight  continued.     The  child  may  have 
been  inherentlv  weak  or  there  may  have  been  a  cow's-milk  idiosyn- 
crasy to  help  account  for  the  lack  of  success  in  the  milk-feeding. 
Usually  there  followed  a  series  of  experiments  with  different  kinds 
of  food  and   methods  of   feeding,  the  vomiting,  diarrhea,  or   colic 
continued  with  wasting,  and  when  the  child  reached  the  dispensary 
or  office  he  was  perhaps  six  months  of  age  and  weighed  from  six  to 
nine  pounds,  presenting  a  typical  athreptic  picture.     Some  of  these 
children  are  born  with  a  digestion  that  is  apparently  incompatible 
with  cow's-milk  mixtures.     Others  have  their  digestive  capacity  for 
cow's  milk  hopelessly  deranged  by  improper  feeding  methods.     The 
majority    of    the    cases   occur    among   the    overcrowded    tenement 
poor— the  w^orst  possible  environment  for  a  delicate  infant.     There 
is  little  or  no  proteid  assimilation,  so  that   any  approximation  to 
normal  growth  is  impossible.     They  may  also  possess  a  poor  fat 
capacity,  and  if  there  is  also  a  diminished  sugar  capacity  the  proteids 
of  the  tissues  are  drawn  upon  to  supply  heat  and  energy,  with 
resulting  progressive  emaciation.     Heredity,  environment,  and  the 
season  of  the  vear,  all  influence  the  prognosis. 

Treatment.— An  important  determining  factor,  however,  as  to  the 
child's  future,  depends  upon  whether  or  not  he  can  have  the  advantage 
of  a  wet-nurse.  That  a  great  majority  of  the  cases  of  simple  athrepsia 
recover,  and  often  recover  promptly,  making  a  most  satisfactory 
growth,  when  a  wet-nurse  is  secured,  is  proof,  as  above  stated,  that 
the  condition  depends  more  upon  the  nature  of  the  nutrition  than 
upon  the  patient,  so  far  as  relates  to  any  peculiar  systemic  state  or 
pathologic  condition.  In  securing  a  wet-nurse  the  physician's  duties 
are  by  no  means  completed.  The  patient  may  not  take  kindly  to 
the  breast  and  he  will  have  to  be  taught  breast-nursing.  A  great 
deal  of  time  may  be  required  in  teaching  older  infants,  those  who 
have  been  on  the  bottle  for  seven  or  eight  months.  To  this  end, 
various  devices  may  have  to  be  used.     For  the  first  nursing  it  is 


152  NUTRITION    AND   GROWTH 

well  to  allow  the  child  to  go  for  an  hour  or  two  beyond  the  feeding- 
time  in  order  that  his  appetite  may  be  voracious.  It  is  advisable 
also  to  give  the  first  few  nursings  in  a  darkened  room  with  the 
person  who  has  been  accustomed  to  feeding  the  patient  very  near. 
Sufhcient  milk  should  be  forced  from  the  breast  to  enable  the  child 
to  taste  it.  A  little  powdered  sugar  sprinkled  on  the  nipple  is  a  good 
means  of  increasing  his  interest.  In  some  instances  it  has  been 
necessary  to  cover  the  wet-nurse  with  a  blanket  or  sheet,  leaving 
only  the  breasts  exposed ;  or  it  may  be  necessary  to  use  the  nipple- 
shield  (Fig.  7)  for  a  few  days  in  order  gradually  to  accustom  the 
child  to  the  change.  I  have  yet  to  see  a  case  in  which  success  did 
not  follow  persistent  effort.  Oftentimes  the  nurse's  milk  will  not 
agree  at  first;  but  this  is  not  surprising  and  need  cause  no  dis- 
couragement. Breast-milk  ordinarily  is  a  much  stronger  food 
than  the  child  has  been  accustomed  to,  and  it  may  produce  vomit- 
ing or  colic  or  diarrhea.  When  indigestion  follows,  the  nurse's 
milk  should  be  modified  by  giving  the  baby  weak  barley-water  or 
plain  boiled  water  before  the  nursing,  in  case  he  nurses  well,  or  after 
the  nursing  in  case  he  nurses  poorly.  One  or  two  ounces  of  breast- 
milk  at  a  feeding  is  all  that  these  patients  can  be  expected  to  take 
during  the  first  few  days.  The  amount  obtained  may  readily  be 
determined  by  weighing  the  patient,  without  the  trouble  of  undressing 
him,  before  the  nursing,  and  then  weighing  him  at  intervals  of  from 
three  to  five  minutes  after  the  nursing  has  commenced.  An  ounce 
of  breast-milk  is  practically  an  ounce  avoirdupois.  These  children, 
if  they  are  not  too  weak,  will  take  greedily  almost  anything  from  the 
bottle.  The  addition  of  an  ounce  or  two  of  barley-water  or  plain 
water  dilutes  the  milk  and  renders  it  easier  of  digestion,  and  furnishes 
at  the  same  time  the  necessary  fluid  for  the  child.  The  most  unprom- 
ising cases  of  marasmus  are  not  to  be  despaired  of,  or  the  treatment  re- 
laxed, although  the  physician  should  be  cautious  in  his  prognosis. 
Hospitals  and  institutions  for  children  always  carry  a  certain  number 
of  these  cases.  It  is  not  infrequent  to  find  miliary  tuberculosis  at 
autopsy  where  it  was  not  suspected  during  life,  no  clinical  signs  of 
fever  having  been  present.  If  the  child  is  too  weak  or  indifferent  to 
swallow,  the  wet-nurse's  milk  may  be  expressed,  diluted,  and  given  by 
gavage.     I  have  in  a  few  instances  peptonized  the  wet-nurse's  milk. 

Illustrative  Case. — The  most  pronounced  and  the  most  hope- 
less recovery  case  coming  under  my  observ^ation  was  seen  by  me 
in  consultation  in  one  of  the  suburbs  of  New  York.  The  child 
was  four  months  old  and  weighed  five  poimds.  He  was  ema- 
ciated to  a  skeleton,  having  weighed  eight  pounds  at  birth.  The 
temperature  for  several  days  ranged  between  92°  and  94°  F.  A 
trained  nurse  and  an  unusually  intelligent  mother  were  in  charge. 
I  doubted  the  accuracy  of  the  thermometer  reading,  and  different 
thermometers  were  used.     The  temperatures  were  taken  by  the  rec- 


marasmus;   athrepsia;    infantile  atrophy  153 

turn.  I  took  the  temperature  myself  on  one  or  two  occasions  with 
my  own  thermometer  and  found  the  reading  correct.  The  attending 
physician  had  also  taken  it  repeatedly,  so  that  there  was  no  doubt 
as  to  the  matter.  The  child  was  too  weak  to  nurse.  The  breasts 
were  accordingly  pumped,  and  for  each  feeding  he  was  given  one-half 
ounce  of  breast-milk  with  an  ounce  of  barley-water,  to  which  a  few 
drops  of  sherry  wine  were  added.  This  was  given  by  gavage  at 
two-hour  intervals.  He  was  wrapped  in  flannel  and  w^ool  and  sur- 
rounded with  hot-water  bottles.  The  food  was  retained  and  digested. 
In  four  days  he  could  nurse,  and  was  allowed  to  take  a  small  amount 
from  the  breast  and  finish  the  meal  with  barley-water.  The  tem- 
perature gradually  rose  to  the  normal.  More  breast-milk  was 
allowed  as  he  proved  able  to  care  for  it,  and  the  child  made  a  perfect 
recovery,  weighing  eighteen  pounds  when  he  was  nine  months  old. 

This  case  demonstrated  to  me  that  a  marasmic  child  is  never  a 
hopeless  case  until  he  ceases  to  live.  Unfortunately  very  few 
marantic  children  can  have  the  benefit  of  a  wet-nurse,  but  without 
her  the  majority  of  these  cases  are  hopeless.  I  have  seen  such  cases 
take  their  modified  milk  or  w^hatever  was  given  them  without 
inconvenience.  The  stools  may  be  offensive  if  cow's  milk  is  given,  or 
there  may  be  constipation  or  the  stools  may  appear  perfectly  normal. 
As  a  rule,  there  is  no  serious  diarrhea  or  any  other  evidence  of  an 
acute  inflammatory  process  in  the  intestine.  However,  in  spite  of 
fairly  normal  stools,  the  patient  grows  thinner  and  thinner.  After 
a  time  all  food  is  refused,  gavage  is  used  as  a  last  resort,  and  the 
child  finally  dies.  The  autopsy  shows  nothing  but  pale  organs  with 
perhaps  a  strip  of  hypostatic  pneumonia.  Now  and  then  one  of 
these  cases  in  a  children's  institution  or  in  a  hospital  recovers  without 
a  wet-nurse,  but  it  is  the  exception  proving  the  rule.  Put  these 
athreptics  on  a  wet-nurse,  as  I  do  at  every  opportunity,  and  many 
of  them  thrive  in  spite  of  the  well-known  unfavorable  influence 
exerted  by  institutional  life  upon  the  very  young.  In  addition  to 
putting  the  athreptic  baby  on  the  wet-nurse,  his  stomach  should  be 
washed  once  daily  and  he  should  live  out  of  doors. 

Outdoor  Life. — Next  to  the  wet-nurse,  I  know  of  no  measure 
fraught  with  so  much  good  as  is  outdoor  life.  The  season  of  the  year 
exerts  considerable  influence  on  the  prognosis.  The  athreptic  bears 
the  heat  and  humidity  very  badly,  and  the  early  summer  mortality  of 
all  large  cities  is  materially  increased  by  these  children,  who  wilt  and 
die  in  institutions  and  tenements  with  the  first  two  or  three  days  of 
continuous  hot  weather.  Parents  of  such  children  residing  in  a  large 
city  who  can  afford  it,  should  send  them  to  the  country  not  later  than 
June  ist,  to  return,  in  this  latitude  (New  York  city),  not  earlier  than 
October  ist.  During  the  day  the  child  should  be  on  a  porch  or  in  the 
shade  continuously.  At  night  the  windows  of  his  sleeping-room 
should  be  wide  open.     During  the  colder  months  if  the  child  is  too  ill 


154  NUTRITION   AND   GROWTH 

to  be  taken  out  of  doors  he  should  have  from  morning  until  evening 
a  continuous  indoor  airing  (page  36),  and  the  sleeping-room  should 
always  communicate  with  the  open  air.  The  roof-garden  in  large 
cities  is  a  most  valuable  aid  in  the  management  of  athreptic  children. 

Tenement  Cases. — While  much  has  already  been  said  about  this 
most  interesting  and  important  subject,  one  phase  of  it  has  not  been 
touched  upon.  I  refer  to  the  athreptic  infant  of  the  tenement,  and 
those  others  in  private  life  for  whom  a  wet-nurse  is  impossible.  They 
furnish  by  far  the  largest  number  of  our  marasmic  patients.  Perhaps 
the  most  frequent  error  in  the  management  of  these  cases  is  an  en- 
deavor to  select  at  the  start  a  food  for  the  child  to  thrive  upon.  In 
doing  this,  almost  invariably  a  stronger  food  is  selected  than  the  child 
is  capable  of  digesting,  and  he  is  made  worse  by  the  attempt.  Our 
ultimate  object  in  these  infants  will  be  more  readily  attained  if,  at 
first,  we  attempt  only  to  supply  the  child  with  a  food  upon  which  he 
can  exist  without  loss  in  weight.  The  number  of  calories  necessary 
for  an  athreptic  child  is  not  great.  It  must  be  remembered,  further- 
more, that  we  are  not  dealing  with  a  case  of  infant-feeding  as  the 
term  is  commonly  understood.  True,  we  are  feeding  an  infant,  but  a 
sick  infant,  and  the  methods  of  feeding  used  in  the  comparatively  well 
do  not  apply  here  in  all  respects.  The  problem  of  nourishing  these 
children  is  to  be  considered  from  two  standpoints — that  of  the  food  and 
that  of  the  baby,  with  special  reference  to  his  organs  of  digestion. 
The  stomach,  in  many  of  these  infants,  is  dilated,  with  a  consequent 
lack  of  motility.  Residual  undigested  food  remains  long  after  feed- 
ing. There  has  been  a  constant  fermentative  change,  with  the  pro- 
duction of  lactic  and  butyric  acids,  resulting  in  local  changes  of  an 
inflammatory  nature  in  the  mucous  membrane  of  the  stomach,  so 
that  not  only  must  the  organ  be  prepared  for  the  food,  but  the  food 
must  be  adapted  to  the  stomach  capacity,  and  when  this  is  done,  when 
both  receive  due  consideration,  we  are  much  more  likely  to  succeed. 

Stomach-washing . — In  all  of  these  cases,  for  the  first  few  days 
of  treatment,  I  wash  out  the  stomach  with  sterile  water,  regard- 
less of  the  presence  of  vomiting  and  regurgitation  and  regardless 
as  to  whether  the  child  is  bottle-fed  or  breast-fed.  It  is  often  sur- 
prising to  note  the  amount  of  thick  mucus  and  undigested  food  that 
will  be  w^ashed  from  a  stomach  from  which  there  has  never  been 
vomiting.  The  daily  washings  enable  the  child  to  take  more  food 
and  stronger  food.  It  may  be  necessary  to  continue  the  washings 
for  days.  They  may  first  be  discontinued  when  the  water  siphons 
clear  and  without  mucus.  They  should  be  repeated  if  there  are 
indications  calling  for  it,  such  as  regurgitation  of  sour  water  or 
mucus  or  a  loss  of  appetite.  In  a  case  seen  recently  in  which  there 
was  chronic  gastritis  with  athrepsia,  washings  were  continued  at 
gradually  lengthened  inters^als  for  six  months. 

Feeding. — If  the  case  is  one  with  pronounced  stomach  involve- 


marasmus;    athrkpsia;    infantile  atrophy  155 

ment,  a  3  percent  milk-sugar  solution  is  given  for  twenty-four  hours 
in  quantity  suitable  for  the  age  and  size  of  the  patient.  The  follow- 
ing day  barley-water  No.  I  is  given,  to  which  sugar  is  added  to  make 
the  mixture  5  percent. 

Cow's  Milk. — While  it  is  doubtful  if  the  child  can  take  cow's 
milk  after  this  period  of  stomach-rest  and  stomach-washing,  it  may 
be  attempted.  Two  drams  of  as  safe  milk  as  can  be  obtained 
is  added  to  every  second  feeding  of  the  barley-and-sugar  water. 
If  it  agrees,  after  a  day  or  two,  two  drams  are  added  to  each  feeding, 
with  a  gradual  increase  of  a  dram  every  two  or  three  days.  The 
intervals  of  feeding,  for  children  under  one  year  of  age,  may  range 
at  from  two  to  three  hours.  It  is  rarely  advisable  to  feed  even  the 
most  delicate  athreptic  oftener  than  once  in  two  hours.  If  the  milk 
can  be  retained  and  assimilated  in  the  strength  of  one-fourth  milk  and 
three-fourths  barley  with  5  percent  sugar,  or  if  an  equal  quantity 
of  milk  and  sugar-water  alone  is  found  to  agree,  the  child  will  begin  to 
grow  and  general  improvement  will  follow  rapidly.  If  the  cow's  milk 
is  not  well  borne,  skimmed  milk  (page  85),  or  a  weak  cream  mixture 
— one-half  dram  of  cream  to  a  feeding — may  be  tried.  It  is  practically 
impossible  to  have  whey  made  properly  outside  of  a  hospital  labora- 
tory or  an  intelligent  home.  In  using  whey  it  may  be  given  in  quan- 
tities suitable  to  the  age  of  the  patient.  The  prescribing  of  cream 
among  the  poor  is  a  hazardous  procedure  for  these  infants.  It  may 
be  old,  improperly  cared  for,  and  swarming  with  bacteria.  If  there 
is  a  tendency  to  looseness  of  the  bowels  the  diarrhea  is  thus  made 
worse.  Cream  mixtures  rarely  succeed  as  foods  for  athreptic  chil- 
dren.    I  use  it  only  among  those  who  can  properly  care  for  it. 

Condensed  Milk. — I  have  found  that  in  the  out-patient  athreptic 
the  much-abused  condensed  milk  fulfils  a  useful  function.  It  is 
the  cleanest  food  we  can  give  the  dispensary  baby.  It  is  the  cheapest, 
the  most  easily  kept,  and  the  most  easily  digested  milk  that  can  be 
furnished  him.  Consequently  when  cow's-milk  feeding  is  imprac- 
ticable or  when  it  disagrees,  I  give  condensed  milk,  beginning  with 
one-half  dram,  which  is  added  to  the  barley-water  or  to  the  plain 
water  for  every  second  feeding,  later  to  every  feeding,  increasing  the 
quantity  gradually  as  the  child  shows  an  ability  to  digest  it.  The 
patient  must  be  seen  frequently  and  the  stools  carefully  examined 
in  order  that  an  increase  in  the  food  strength  may  be  made  as  soon  as 
conditions  allow.  The  mother  is  told  to  bring  the  napkins  to  the 
dispensary,  the  child  is  weighed  at  each  visit,  every  second  day, 
and  it  is  most  gratifying  to  see  how  well  some  of  them  gain  in  weight, 
not  because  they  are  getting  an  ideal  food  by  any  means,  but  because 
it  fits  the  case,  temporarily.  Condensed  milk  is  thus  used  as  a 
stepping-stone  to  something  better.  When  the  child  has  taken  it  with 
benefit  for  a  month  or  six  weeks,  cow's  milk  is  attempted  if  the  time 
of  the  year  is  between  October  and  the  following  June.     After  June  ist 


156  NUTRITION    AND   GROWTH 

I  would  continue  with  condensed  milk,  as  a  baby  showing  some  degree 
of  anemia  and  rachitis  as  the  cooler  months  approach  is  to  be  pre- 
ferred to  the  risk  of  attempting  cow's-milk  feeding,  with  poor  milk, 
in  the  hands  of  overworked  or  ignorant  mothers. 

In  beginning  cow's  milk,  in  order  to  avoid  sudden  radical  changes  I 
replace  one  feeding  of  the  condensed-milk  mixture  daily  with  one  feed- 
ing of  a  weak  cow's-milk  mixture.  In  some  cases  this  will  produce 
illness  and  must  be  stopped ;  in  others,  it  will  be  well  borne.  When 
it  is  found  to  agree,  two  feedings  should  replace  two  condensed- 
milk  feedings  daily.  In  this  way,  by  increasing  by  one  the  number 
of  cow's-milk  feedings  every  third  or  fourth  day,  entire  cow's-milk 
feeding  may  safely  be  inaugurated.  The  strength  of  the  cow's  milk 
should  not,  of  course,  correspond  to  that  suggested  for  well  babies. 
For  a  child  of  six  months  a  three-months'  formula  may  be  given. 
As  the  child  improves,  the  strength  of  the  milk  may  correspondingly 
be  increased.  In  this  way  1  have  treated  successfully  a  great  many 
tenement  athreptics. 

Some  children  will  be  able  to  take  and  properly  care  for  only 
two  cow's-milk  feedings  daily;  others  will  take  every  second  feed- 
ing of  cow's  milk.  I  have  a  patient  at  the  present  time  aged  four- 
teen months.  He  will  take  two  cow's-milk  feedings  daily  with  com- 
fort, but  when  the  third  is  given  he  is  invariably  made  ill.  Some 
will  not  be  able  to  take  a  particle  of  cow's  milk.  When  this  is  the 
case,  the  condensed  milk  should  be  combined  with  a  gruel,  such  as 
oatmeal,  which  contains  a  high  percentage  of  proteid.  These  cases 
may  also  be  given  beef- juice  at  a  very  early  age.  I  often  use  pure 
cod-liver  oil,  from  fifteen  to  thirty  drops,  which  is  usually  taken  three 
times  daily  without  disturbance.  The  tenement  athreptic  is  given 
the  benefit  of  as  much  fresh  air  as  possible.  He  is  also  given  the 
advantage  of  the  daily  tub-bath  and  the  oil  rub. 

MALNUTRITION  IN  INFANTS 
I  am  often  asked  by  students  the  difference  between  malnutrition 
and  marasmus  in  infants.  While  hard  and  fast  lines  cannot  be  drawn 
as  to  where  malnutrition  ends  and  marasmus  begins,  there  is  a  vast 
difference  between  the  two  conditions.  Malnutrition  may  best  be 
described  as  the  first  stage  of  marasmus.  Every  child  with  marasmus 
must  first  have  undergone  a  longer  or  shorter  period  of  malnutrition. 
In  malnutrition  the  infant  is  under- weight,  his  gain  being  slow  and 
irregular,  the  muscles  are  soft,  and  if  the  condition  persists,  bone 
changes,  indicating  rachitis,  appear.  Malnutrition  may  be  the 
result  of  faulty  digestion  and  assimilation  engrafted  upon  faulty 
feeding,  often  combined  with  overfeeding.  The  patient  shows 
evidence  of  indigestion  in  a  distended  abdomen  and  in  stools  that 
are  far  from  the  normal,  or  there  may  be  no  intestinal  derangement 
whatever,  the  malnutrition  being  due  to  the  fact  that  the  child's 
diet  for  months  had  consisted  of  food  that  did  not  contain  the 


MALNUTRITION    OF    INFANTS 


157 


nutritional  elements  required.  Infants  who  subsist  on  a  diet  of 
condensed  milk  or  the  malted  infant  foods,  without  cow's  milk, 
almost  invariably  show  signs  of  general  malnutrition. 

A  case  due  to  high-fat  feeding  was  recently  seen  by  me.  The 
patient  was  a  male,  six  months  of  age,  weighing  thirteen  pounds, 
resident  of  a  New  York  suburb  where  the  conditions  are  most 
healthful.  His  fontanel  was  slightly  depressed,  the  muscles  were 
soft  and  flabby,  the  ribs  beaded,  and  the  child  had  lost  his  appetite 
and  suffered  from  constipation.  A  history  of  the  feeding  showed 
that  he  had  been  getting  a  cow's-milk  mixture  containing  approx- 
imately 6  percent  fat,  4  percent  sugar,  and  2  percent  proteid.  In 
this  patient  the  indigestion,  loss  of  appetite,  and  constipation 
were  unquestionably  due  to  the  high  percentage  of  fat.  The  energy 
exerted  in  digesting  the  food  almost  counterbalanced  the  benefit 
derived  from  it,  the  result  being  a  very  slow  gain  in  weight. 

Treatment. — Diet. — The  management  of  malnutrition  due  to  such 
causes  consists  in  correcting  the  digestive  errors,  in  using  castot  oil  or 
calomel  with  stomach-washing,  and  in  adjusting  the  food  to  the  child's 
requirements  and  digestive  capacity,  alw^ays  remembering  that  a  child 
who  should  have  from  3  to  4  percent  of  fat  cannot  be  expected  to 
thrive  on  i  percent,  as  is  the  case  when  condensed  milk  is  given;  nor 
can  he  be  expected  to  thrive  when  the  use  of  a  6  percent  cow's-milk 
mixture  is  long  continued.  Likewise  very  low  proteid  or  very  high 
proteid  will  be  followed  by  malnutrition,  the  one  producing  indiges- 
tion and  interference  with  the  assimilative  powers,  the  other  supply- 
ing too  little  nutrition  to  the  organism.  In  either  event,  the  child 
does  not  get  the  nutrition  required.  The  amount  of  proteid  given  in 
condensed  milk  is  rarely  above  0.5  percent.  The  proprietary  meal 
foods  and  condensed  milk  mentioned  elsewhere  are  useful  in  certain 
types  of  illness  and  in  convalescence  from  illness.  They  must  not, 
however,  be  selected  as  the  sole  articles  of  diet.  A  mistake  fre- 
quently made  in  the  feeding  of  these  cases  is  to  give  the  food  at  too 
frequent  intervals.  At  the  sixth  month  three-hour  feedings,  six 
in  twenty-four  hours,  are  best,  even  though  the  food  is  weak.  The 
stomach  will  bear  stronger  food  sooner  when  given  at  longer  intervals 
than  it  will  when  given  at  intervals  of  two  and  one-half  hours. 
When  the  child  is  nine  or  ten  months  of  age,  four-hour  intervals 
usually  answer  best.  In  some  it  may  be  necessary  to  continue  with 
the  three-hour  feedings.  Cow's  milk  should  be  the  basis  of  the 
diet,  given  according  to  the  suggestion  in  the  section  on  IMarasmus. 
In  many  cases  cereal  gruels  made  from  barley  or  oatmeal  may  be 
added  with  advantage.  Malt  soup  (page  98)  may  often  be  used 
with  success  in  these  patients.  A  milk  formula  below  that  indicated 
by  the  child's  age  may  have  to  be  given  for  a  long  time.  Thus,  w^hen 
six  months  of  age  he  may  be  able  to  take  but  a  three-months'  formula ; 
when  nine  months  of  age,  a  six-months'  formula.  I  have  constantly 
under  my  care  infants  who  cannot  take  cow's-milk  mixtures  cor- 


158  NUTRITION    AND   GROWTH 

responding  in  strength  to  that  usually  taken  by  well  infants  of  the 
same  age. 

Hygiene. — Attention  to  the  matter  of  outdoor  life,  indoor  airing  on 
inclement  days,  and  residence  in  the  country  during  the  heated  term 
is  of  great  importance  in  the  general  management.  During  the 
cooler  months  the  child  should  receive  inunctions  of  unsalted  lard 
or  goose  oil  after  the  daily  evening  bath.  Constipation,  if  present, 
is  treated  by  the  oil  method  (see  page  173). 

TARDY  MALNUTRITION 

Malnutrition  with  tuberculosis  and  syphilis  is  not  a  part  of  our 
subject.  In  the  sections  on  Malnutrition  in  Infants  and  Children 
it  may  be  thought  by  some  that  there  is  repetition  of  what  is  said 
under  the  title  of  The  Delicate  Child.  While  the  management  neces- 
sarily is  along  the  same  hues,  two  distinct  types  of  children  are 
represented.  The  marasmic  and  malnutrition  infant  or  young  child 
may  be  but  temporarily  delicate.  When  the  simple  malnutrition 
case  recovers  it  may  develop  into  as  normal  a  specimen  of  robust 
childhood  as  could  be  desired.  The  delicate  child  as  I  have  endeav- 
ored to  describe  him  is  inherently  delicate,  and  our  efforts  are  toward 
improving  his  condition,  with  the  hope  perhaps,  but  with  no  great 
assurance,  that  he  will  some  time  become  a  robust  adult.  Tardy 
malnutrition  is  seen  in  children  of  the  school-age.  They  are  deficient 
in  weight,  in  resistance  to  disease,  and  in  capacity  for  work;  they 
are  pale,  thin,  tired  children. 

Etiology. — Cases  of  tardy  malnutrition  as  well  as  those  of  maras- 
mus and  infantile  malnutrition  are  seen  in  all  the  walks  of  life, 
among  the  wealthy,  the  so-called  middle  class,  and  among  the  poor. 
Strange  as  it  may  seem,  these  cases,  regardless  of  the  station  in  life, 
have  one  cause  common  to  all — defective  feeding.  The  scion  of 
wealth  who  is  overfed,  or  badly  fed — given  food  which  is  unsuitable, 
and  allowed  the  promiscuous  use  of  sweets — may  develop  malnutri- 
tion just  as  effectively  as  the  child  of  the  tenement  who  subsists  on 
fried  meats,  grocery  milk,  boxed  breakfast  foods,  and  other  nonde- 
script products  of  the  bakery  around  the  comer.  There  is  a  painful 
lack  of  knowledge  among  all  classes  as  regards  the  nourishment  re- 
quired by  a  growing  child.  He  is  fed  to  satisfy  his  appetite,  and 
when  this  is  accomplished  the  parents  believe  that  their  duty  is 
done.  How  far  they  fall  short  of  proper  feeding  is  demonstrated 
daily  in  out-patient  clinics  and  in  private  work.  Poverty  is  an  oc- 
casional cause  of  bad  feeding  in  New  York  city. 

Treatment. — I  have  repeatedly  seen  children  from  five  to  ten  years 
of  age  with  marked  malnutrition  gain  from  three  to  five  pounds  the 
first  month  under  treatment  which  consisted  simply  in  giving  food 
that  they  had  a  right  to  demand,  properly  prepared  at  definite  inter- 
vals. The  school-child  sufi"ering  from  malnutrition  should  be  re- 
moved from  school  temporarily  and  as  much  outdoor  life  as  possible 


TARDY    MALNUTRITION 


159 


should  be  enjoyed  by  him,  regardless  of  his  station  in  life.  Every- 
thing of  a  strenuous  nature  should  be  avoided.  He  should  be  put  to 
bed  early  and  encouraged  to  sleep  late.  A  midday  rest  for  one  who 
shows  marked  emaciation  and  diminished  resistance  is  advised. 

Illustrative  Case. — The  following  is  quite  a  normal  history  of  an 
advanced  case  of  malnutrition  in  a  girl  seven  years  of  age,  and  the 
treatment  is  that  which  we  usually  employ.  The  mother  brought  the 
girl  to  the  out-patient  service  at  the  New  York  Polyclinic  because  the 
child  was  pale,  did  not  grow,  and  was  always  tired — too  tired  to  go  to 
school,  of  which  she  was  very  fond,  too  tired  to  play  with  other  chil- 
dren, as  had  previously  been  her  custom.  There  was  loss  of  appetite, 
no  food  being  taken  except  on  compulsion.  Her  weight  was  forty-one 
pounds,  her  appearance  as  above  described.  There  was  no  evidence 
of  congenital  syphilis  or  tuberculosis.  There  was  a  secondary  ane- 
mia. The  child  slept  in  a  badly  ventilated  room,  she  drank  tea  and 
coffee.  Cake,  pastry,  and  sweets  were  her  regular  diet,  and  because 
she  did  not  eat  at  meal-times  she  w^as  allowed  to  eat  between  meals 
whenever  and  whatever  she  pleased.  The  following  mode  of  life  and 
diet  was  prescribed.  She  was  to  sleep  in  the  front  room,  known  as  a 
sitting-room  or  parlor,  with  a  window  open  at  least  six  inches.  She 
was  given  three  meals  a  day  with  nothing  whatever  between  meals. 
The  diet  consisted  of  red  meat  once  a  day,  two  or  three  soft-boiled 
eggs  daily,  one  quart  of  good  milk  daily  if  it  agreed,  and  it  did  agree. 
She  was  to  have  only  natural  cereals,  such  as  oatmeal,  cracked 
wheat,  and  cornmeal — each  of  which  was  to  be  cooked  three  hours 
the  day  before  it  was  to  be  given.  Baked  or  boiled  potatoes  and 
one  green  vegetable  were  to  form  a  part  of  the  dinner  at  midday. 
Stewed  and  raw  fruits  and  plain  puddings  with  home-made  bread 
and  plenty  of  butter  completed  the  dietary.  She  was  put  to  bed  at 
7  o'clock  and  arose  at  7  the  following  morning.  An  after-dinner  rest 
in  a  darkened  room  for  an  hour  was  insisted  upon.  Before  retiring 
she  was  given  a  brine  bath  (page  31),  followed  by  a  brisk  drying  with 
a  rough  towel,  after  which  her  entire  body  was  rubbed  for  ten  min- 
utes with  olive  oil.  In  one  month  a  radical  change  had  taken  place. 
She  had  gained  four  pounds  in  weight.  Her  color  was  good.  She 
complained  no  more  of  languor  or  fatigue.  She  was  eager  for  sckool. 
The  improvement  continued,  and  in  ten  weeks  she  made  a  perfect 
recovery.  In  not  every  case  will  results  be  so  prompt  and  satisfac- 
tory, in  some,  a  longer  time  will  be  required  before  pronounced 
results  are  to  be  seen.  Every  child  suffering  from  malnutrition  of 
this  type  cannot  help  being  benefited  more  or  less  by  such  a  regime. 

Tonics. — The  tincture  of  nux  vomica,  four  drops  in  water  before 
meals,  is  sometimes  given  to  these  children  in  whom  the  appetite  is  de- 
fective ;  or  one  grain  of  the  citrate  of  iron  and  quinin  may  be  given 
in  one  dram  of  equal  parts  of  sherry  wine  and  water.  If  constipa- 
tion is  present,  the  oil  treatment  (page  174)  should  be  instituted. 


GASTRO-ENTERIC  DISEASES 

ACUTE  INTESTINAL  INDIGESTION 
This  disorder  is  first  referred  to  because,  according  to  my  obser- 
vation, it  is  the  most  frequently  seen  of  the  intestinal  disorders. 
Its  importance  not  being  recognized,  it  receives  but  little  considera- 
tion in  its  bearing  upon  prophylaxis  and  treatment.  The  proper 
appreciation  and  management  of  a  disordered  intestinal  function 
are  essential  to  the  solution  of  that  most  important  problem — summer 
diarrhea.  As  pointed  out  elsewhere,  the  intestine  which  furnishes 
the  most  fertile  field  for  bacterial  growth  is  the  intestine  which  is 
persistently  deranged. 

The  mortality  of  summer  diarrhea  in  June  in  Greater  New  York 
in  children  under  two  years  of  age  is  usually  but  from  three  hundred 
to  five  hundred  less  than  in  August.  The  high  June  mortality  has 
been  explained  by  the  fact  that  it  includes  many  cases  of  malnutri- 
tion and  marasmus ;  but  it  must  be  remembered  that  it  includes  also 
cases  of  a  diminished  intestinal  resistance,  which  are  ready  subjects 
for  the  almost  invariable  exposure  to  which  every  bottle-fed  infant 
is  subjected  at  some  time  during  the  summer,  when  heat  and  humid- 
ity aid  in  lowering  the  general  vitality — exposure  through  infected 
food.  A  close  investigation  of  hundreds  of  cases  of  severe  acute 
disorders  of  infants  has  shown  that  a  great  majority  of  them  are  not 
as  acute  as  a  superficial  history  would  indicate.  A  complete  history 
in  a  case  of  acute  gastro-enteric  infection  (cholera  infantum)  or 
in  an  apparently  severe  intestinal  infection  with  resulting  colitis, 
or  in  an  acute  colitis  (dysentery),  will  show  that  the  child  had 
defective  intestinal  digestion  during  the  previous  cold  months, 
and  that  the  grave  condition  which  he  presented  when  brought  for 
treatment  had  been  preceded  for  two  or  more  days  by  simple  diar- 
rhea, probably  without  vomiting  and  with  little  fever,  but  he  did 
have  green  passages  and  he  did  have  diarrhea.  He  therefore  had 
intestinal  indigestion  before  the  urgent  symptoms  of  fever  and  pros- 
tration developed.  In  about  i  percent  of  the  cases  of  severe  gastro- 
enteric diseases  of  children  in  summer  the  onset  is  sudden,  without 
warning  and  with  urgent  symptoms. 

Treatment. — The  time  to  treat  these  cases  of  intestinal  indiges- 
tion, in  order  to  be  most  effective  in  the  prevention  of  severe  toxemia 
and  grave  lesions,  is  before  the  physician  sees  the  patient.  The  reduc- 
tion in  the  mortality  rests  in  the  education  of  the  mother  to  the  point 
of   realizing  that  a  loose  green  stool  is  a  danger-signal.     When  it 

1 60 


PERSISTENT   INTESTINAL   INDIGESTION  l6l 

occurs,  she  is  to  give  a  dose  of  castor  oil,  stop  the  bottle  or  stop  the 
breast,  and  give  the  baby  boiled  water  or  barley-water  until  the 
physician  can  see  the  patient.  Any  physician  who  has  children 
under  his  care,  whether  in  hospital,  institution,  out-patient,  or  pri- 
vate practice,  and  who  does  not  so  instruct  the  nurse  or  mother, 
fails  in  his  obligation  as  a  practitioner  of  medicine. 

In  the  Breast-fed. — Intestinal  disease  of  severity  in  infants  fed  en- 
tirely on  the  breast  is  exceedingly  rare.  In  a  breast-fed  baby  it  may 
be  necessary  to  discontinue  nursing  for  from  twelve  to  thirty-six  hours. 
The  child  is  given  one  or  two  drams  of  castor  oil  and  barley-water  or 
rice-water  No.  i  (seepage  124),  to  which  one-half  or  one-fourth 
ounce  of  cane-sugar  is  added  to  the  pint.  While  nursing  is  discon- 
tinued the  breasts  should  be  pumped  at  the  regular  nursing  hour  so 
as  to  keep  up  the  flow  of  milk  and  relieve  the  pressure.  Rarely  wdll 
other  treatment  be  required. 

In  the  Bottle-fed. — In  the  bottle-fed,  greater  caution  will  be  neces- 
sary. The  management  consists  in  continuing  the  carbohydrate  diet, 
which  the  well-trained  mother  has  begun,  until  the  stools  approximate  ' 
the  normal,  which  may  necessitate  an  abstinence  from  milk  for  three 
or  four  days,  bv  which  time  it  may  usually  be  resumed.  In  resuming 
the  milk  it  should  always  be  given  in  reduced  quantities  for  the  first  day. 
One-half  ounce  of  skimmed  milk  may  be  added  to  every  second  feed- 
ing or  to  every  feeding  of  the  gruel.  If  it  is  w^ell  digested  and  causes  no 
return  of  the  diarrhea,  the  amount  of  milk  may  be  increased  tenta- 
tively every  day  or  two  by  the  addition  of  one-half  ounce  to  each 
feeding. 

PERSISTENT  INTESTINAL  INDIGESTION 
A  greater  part  of  this  subject  has  been  covered  in  the  consideration 
of  the  management  of  malnutrition  and  marasmus.  It  is  again 
referred  to  here  in  order  to  call  attention  to  those  cases  which, 
though  mild  in  character,  are  so  important  an  etiologic  factor  in  the 
acute  intestinal  diseases  of  summer.  There  is  perhaps  not  enough 
bow^el  disturbance  to  interfere  with  the  nutrition,  but  we  have 
learned  that  a  considerable  part  of  the  summer  mortality  of  acute 
intestinal  diseases  occurs  in  children  who  have  a  reduced  intestinal 
resistance  as  a  result  of  persistent  intestinal  indigestion. 

A  considerable  number  of  infants  do  not  have  normal  bowel 
evacuations  even  for  two  days  out  of  ten.  There  is  constipation 
which  is  neglected,  or  there  is  a  passage  of  undigested  or  loose 
stools.  In  some  cases  constipation  alternates  with  diarrhea. 
Occasionallv  there  is  a  sharp  attack  of  diarrhea  with  fever.  In 
getting  the  history  of  our  cases  regardless  of  the  nature  of  the  illness, 
we  often  learn  that,  as  a  rule,  the  infants  have  undigested  stools. 
There  is  always  an  unstable  intestinal  equilibrium.  This  condition 
of  intestinal  indigestion  is  almost  without  exception  due  to  errors 


1 62  GASTRO-ENTERIC   DISEASES 

in  diet — either  unsuitable  articles  of  food  being  given  habitually,  or 
the  food  is  too  strong  or  the  feeding  intervals  too  short. 

Treatment. — The  management  of  each  case  is  determined  by  the 
age  of  the  patient  and  the  conditions  of  the  family,  and  will  be  dis- 
cussed in  the  sections  relating  to  Nutrition,  Substitute  Feeding,  and 
Modification  and  Adaptation  of  Foods. 

PERSISTENT  INTESTINAL  INDIGESTION  IN  OLDER  CHILDREN 
In  such  cases  there  may  be  a  sufficient  absorption  of  toxins  of 
an  unknown  nature  from  the  intestinal  canal  to  produce  a  wide  range 
of  symptoms.  Whether  this  causes  pathologic  conditions  in  other 
organs  it  is  not  possible  to  state.  It  is  assumed,  however,  that  it 
does.  Comparatively  little  attention  appears  to  have  been  given  the 
subject.  There  is  no  doubt  whatever  that  it  is  a  factor  of  great 
importance  in  the  nutritional  and  the  so-called  functional  nervous 
'disorders  of  childhood.  One  reason  why  little  attention  has  been 
called  to  the  intestinal  tract  as  an  etiologic  factor  is  perhaps  because 
the  child  is  not  necessarily  constipated.  Intestinal  toxemia  may  exist 
with  one  or  two  apparently  normal  passages  daily  and  even  without 
the  presence  of  indican  in  the  urine. 

In  mv  cases  the  conditions  in  which  it  has  seemed  to  play  a 
part  sufficient  to  form  a  symptom-complex  have  been  in  habitual 
headache,  in  disorders  of  speech,  choreic  in  character,  in  secon- 
darv  anemia,  in  habitual  sleep-talking,  in  sleep-walking,  and  in  gen- 
eral irritability  without  apparent  cause.  Well  children  are  natur- 
ally bright  and  happy.  When  a  child  is  persistently  cross  and 
irritable,  he  is  not  a  well  child.  Chronic  papular  eczema  has 
proved  to  be  of  intestinal  origin  in  a  considerable  number  of  my 
cases,  particularly  among  the  out-patient  class.  The  condition 
often  regarded  and  treated  as  malaria  is  not  infrequently  due  to 
intestinal  toxemia.  Fever  of  a  degree  or  two  may  be  present  for 
protracted  periods.  Nearly  every  case  which  has  come  under  my 
care  had  been  given  at  some  time  or  other  a  course  of  quinin. 
Such  a  patient  is  very  apt  to  be  habitually  tired  and  languid.  He 
may  be  fairly  bright  early  in  the  day,  but  in  the  afternoon  he  yawns 
and  complains  of  being  tired  and  sleepy.  The  blood  examination 
fails  to  reveal  signs  of  malarial  infection,  and  quinin  in  full  doses 
furnishes  no  relief.  The  appetite  may  be  satisfactory,  the  tongue 
may  show  no  signs  of  digestive  disorder.  The  symptom-complex 
which  suggests  to  the  mother  the  thought  of  worms  is  usually  the 
manifestation  of  intestinal  toxemia. 

Illustrative  Cases. — An  interesting  case  of  this  nature  came  under 
my  care  a  few  years  ago.  The  boy,  aged  three  years,  highly  ner- 
vous and  irritable,  was  afflicted  with  day  terrors — pavor  diurnum. 
The  attention  of  the  nurse  was  attracted  to  the  condition  by  the 
boy,  who  asked  that  the    "bugs"   be   removed  from    his  lap-robe 


PERSISTENT    INTESTINAL    INDIGESTION    IN    OLDER    CHILDREN       1 63 

when  he  was  in  his  go-cart.  It  was  in  the  middle  of  winter  and 
there  were  no  bugs  present.  I  fortunately  saw  the  boy  on  one  of 
these  occasions  and  asked  him  to  pick  up  a  bug,  which  he  tried  to 
do  with  his  lingers.  He  could  not  understand  why  he  could  not 
catch  them.  In  this  child  the  tongue  was  heavily  coated  and  there 
was  moderate  constipation,  a  laxative  being  required  every  third 
day.  There  was  an  excess  of  indican  in  the  urine.  The  boy  was 
taking  a  large  amount  of  rich  cow's  milk  daily.  After  stopping 
this,  a  full  dose  of  rhubarb  and  soda  was  given  daily  and  the  boy 
was  well  in  a  week. 

A  boy  five  years  old,  under  treatment  at  the  time  of  writing,  was 
brought  to  me  because  of  disturbance  of  speech.  He  was  normal 
until  three  and  one-half  years  of  age,  when  he  had  difficulty  in  the 
formation  of  entire  words.  This  had  increased  with  the  development 
of  other  nervous  phenomena.  There  was  marked  incoordination  in 
speech — dysarthria — due  to  choreic  movements  evidently  of  the 
tongue  and  laryngeal  muscles.  The  boy  was  exceptionally  well 
nourished  and  there  was  an  absence  of  choreic  movements  in  other 
parts  of  the  body.  The  knee  reflexes  were  considerably  increased. 
He  was  easily  excited.  Hard  play  was  followed  by  restless  nights, 
and  he  talked  in  his  sleep  every  night,  regardless  of  the  habits  of  the 
day.  Inquiry  into  the  diet  failed  to  elicit  any  grave  errors.  He  drank 
one  quart  of  milk  daily,  but  milk  had  never  agreed  with  him  as  an 
infant.  The  bowels  moved  once  daily.  The  movements  were  often 
of  foul  odor  and  the  mother  stated  that  she  was  satisfied  they  were 
too  small.  The  case  after  three  weeks  showed  striking  improvement 
on  a  non-milk  diet  with  a  daily  laxative. 

A  third  case  seen  was  a  girl  six  years  of  age  who  lived  in  the  best 
surroundings  in  a  country  district.  She  was  pale,  rather  thin,  and 
below  weight  for  her  age.  She  was  chronically  tired  and  irritable 
and  had  been  so  for  two  years.  Examination  of  the  blood  showed 
a  secondary  anemia,  and  of  the  urine  a  marked  excess  of  indican. 
She  had  been  taking  quantities  of  quinin.  There  was  no  constipation, 
the  child  had  an  indifferent  appetite.  She  favored  milk  and  was 
paid  for  drinking  extra  quantities  of  it — about  two  quarts  daily  being 
taken.  Marked  improvement  followed  the  treatment  by  an  ab- 
sence of  milk  from  the  diet  and  laxatives,  after  which  she  passed 
from  my  observation. 

The  condition  of  intestinal  toxemia  is  probably  due  to  changes 
taking  place  in  the  proteid  content  of  the  intestine.  In  the  three 
cases  mentioned,  milk  was  a  considerable  part  of  the  diet;  in  fact, 
in  the  majority  of  my  cases,  milk  had  been  taken  in  considerable 
quantities. 

Treatment. — In  my  experience  the  management  of  these  cases, 
which  has  been  most  successful,  has  been  the  discontinuance  of 
cow's  milk,  with  the  further  dietetic   suggestions  of  but   one   egg 


164  G ASTRO-ENTERIC   DISEASES 

every  second  day,  with  meat  but  once  daily.  Cereals,  fruit,  and 
vegetables  are  taken  as  suggested  in  the  dietary  (page  128).  In 
place  of  cow's  milk,  malted  milk  is  given,  and  to  facilitate  the 
bowel  action,  a  raw  apple  is  given  in  the  middle  of  the  afternoon. 
The  patient  takes  an  after-dinner  rest  for  an  hour  or  two.  If  the 
constipation  is  obstinate,  rhubarb  and  soda  of  the  following  strength 
is  used: 

I^.     Pulveris  rhei S*"-  ^X. . 

Sodii  bicarbonatis gr.  viij 

Syrupi  rhei  aromatic! 3ss 

Aquae q.  s.  ad  3  j 

M.  ft. 

Sig. — One  teaspoonful  once  or  twice  daily 

Or,  what  I  prefer,  if  the  child  can  take  a  capsule,  is  the  following 
for  a  child  from  five  to  eight  years  of  age: 

I^.     Tinctur£e  belladonnae gtt.  ij 

Tincturae  nucis  vomicae gtt.  iv 

Extracti  cascarae  sagradae gr.  j-iij 

Sodii  bicarbonatis gr.  iij 

M.  ft.  capsula  No.  i. 

Sig. — To  be  taken  at  bedtime. 

The  medication  may  be  continued  for  three  or  four  weeks,  after 
which  time  one  dram  of  the  syrup  of  the  hypophosphites  (Gardner's) 
may  be  given  three  times  a  day.     This  may  be  alternated  with : 

J^.     Ferri  et  ammonii  citratis gr.   xxiv 

Elixiris  simplicis gtt.  xv 

Aqua; q.  s.  ad  0  iv 

Sig. — One  teaspoonful  three  times  daily  after  meals. 

In  the  event  of  constipation  following  the  use  of  the  laxative, 
the  oil  treatment  (page  174)  may  be  brought  into  use  and  continued 
until  the  condition  is  relieved. 

COLIC 
But  few  children  complete  their  first  year  without  having  severe 
attacks  of  colic.  In  some  cases  the  child  thrives  in  spite  of  the 
attacks,  in  others  such  a  grave  degree  of  indigestion  exists  that  the 
condition  may  prove  most  serious.  The  character  of  both  human 
and  cow's  milk,  its  ready  decomposition  in  the  intestine,  with  the 
formation  of  gas,  together  with  the  lack  of  development  of  the 
infant's  digestive  apparatus,  explain  in  no  small  degree  the  frequency 
of  colic  in  the  young.  When  cow's  milk  is  used  as  in  the  bottle-fed, 
we  are  dealing  with  a  substance  foreign  to  the  infant's  digestive 
apparatus,  and  often  colic  is  the  outcome.  Any  condition  that 
will  give  rise  to  indigestion  may,  of  course,  be  a  cause  of  colic.  Those 
nursing  or  feeding  on  quantities  that  are  too  large  or  on  milk  too 


COLIC  165 

Strong  or  too  frequently  given  are  the  usual  subjects  of  colic.  Proba- 
bly the  most  frequent  cause  of  colic  is  an  indigestion  of  the  proteid 
of  the  milk.  Either  the  proteid  is  in  excess  or  the  child  has  a  poor 
proteid  capacity.  Not  a  few  cases  of  coHc  are  due  secondarily  to 
defective  bowel  action.  A  passage  occurs  each  day,  but  in  too 
small  amount.  There  is  a  continual  fecal  residue  in  the  intestine 
which  undergoes  decomposition  with  gas-formation.  Cold  feet  are 
often  associated  with  colic.  Fright,  anger,  fatigue,  excitement — 
any  condition,  in  short,  which  may  make  a  sufficiently  unfavorable 
impression  upon  the  child's  nervous  organism,  may  produce  indi- 
gestion and  colic. 

Likewise  any  adverse  nervous  mental  state  in  the  mother  may 
produce  colic  in  the  breast  baby.  Constipation  in  the  mother  is 
not  an  infrequent  cause. 

Treatment. — Repeatedly  I  have  had  under  my  care  nursing 
babies  who  suffered  from  habitual  colic  and  who  recovered  after 
the  regulation  of  the  mother's  bowels  by  exercise,  diet,  and  medica- 
tion. In  other  breast  cases  in  which  the  mother's  milk  upon  re- 
peated examination  proves  too  strong  and  the  child  suffers  daily 
from  colic,  a  dilution  of  the  milk  may  be  made  by  the  use  of  plain 
water  or  barley-water,  from  one-half  ounce  to  one  and  one-half 
ounces  of  the  diluent  being  given  before  each  nursing.  In  addition 
to  the  above,  the  bowels  of  the  colicky  infant  should  move  at 
least  twice  daily,  morning  and  evening.  When  this  does  not  take 
place  readily  a  simple  laxative,  such  as  milk  of  magnesia,  one- 
half  to  one  teaspoonful,  or  ten  to  thirty  drops  of  aromatic  cascara 
sagrada,  may  be  given  daily.  Under  no  condition  should  a  child 
subject  to  colic,  be  allowed  to  go  without  a  bowel  evacuation  for 
more  than  twenty-four  hours. 

Diet. — The  dietetic  management  of  colic  in  the  bottle-fed  consists 
in  adapting  the  food  to  the  child's  digestive  capacity.  The  bottle 
baby  may  have  habitual  colic  moderately  and  thrive,  but  he  does 
it  on  an  imperfectly  adapted  food.  Here,  as  in  the  breast-fed,  the 
condition  is  usually  dependent  upon  an  excessive  casein  supply  or 
a  diminished  casein  capacity.  The  matter  of  the  adjustment  of  cow's- 
milk  proteid  in  indigestion  is  discussed  in  detail  under  Milk  Adap- 
tation (page  94).  It  is  sufficient  to  say  that  the  colicky  bottle 
baby  should  have  long  intervals  between  feedings — usually  one-half 
hour  longer  than  otherwise  allowed.  Digestion  is  slower  in  many 
of  these  cases,  although  in  other  respects  they  may  be  healthy 
children.  In  some  the  indigestion  and  pain  are  so  severe  that  a 
perfect  adaptation  of  cow's  milk  is  impossible,  and  some  other  food 
than  cow's  milk  will  be  required. 

Enemas. — The  prevention  of  colic,  then,  it  will  be  seen,  rests 
upon  a  proper  adjustment  of  the  food.  The  immediate  attack  is 
usually  best  relieved  by  the  use  of  an  enema  at  110°  F.  of  a  normal 


1 66  GASTRO-ENTERIC   DISEASES 

salt  solution  or  of  soapsuds,  which,  by  inducing  a  movement  of  the 
bowels,  allows  the  gas  to  escape. 

Medication. — A  soda  mint  tablet  dissolved  in  one  ounce  of  hot 
water,  given  in  one-teaspoonful  doses  repeated  at  five-minute  in- 
tervals, is  sometimes  successful.  For  a  child  under  one  year  of  age 
three  drops  of  spts.  getheris  comp.  (Hoffman's  anodyne)  may  be  given 
in  two  teaspoonfuls  of  hot  water  and  repeated  at  ten-minute  inter- 
vals. From  five  to  ten  drops  of  gin,  when  given  in  three  teaspoonfuls 
of  hot  water,  may  be  used,  and  repeated  in  from  ten  to  fifteen  minutes 
if  the  attack  continues. 

Hot  Applications. — Hot  applications  to  the  abdomen  are  often 
grateful  to  the  patient.  For  this  purpose  ten  drops  of  turpentine 
in  one  quart  of  water  at  120°  F.  may  be  used  with  benefit.  A 
flannel  is  wrung  out  of  the  water  or  the  solution  and  applied  over 
the  abdomen  and  covered  with  a  dry  piece  of  flannel.  The  dressing 
may  be  changed  every  ten  or  fifteen  minutes. 

Opium  and  its  derivatives  should  not  be  used  in  the  treatment 
of  colic.  It  may  relieve  the  pain  temporarily,  but  it  aggravates 
the  condition  to  which  the  colic  is  due. 

BOWEL  FUNCTION 
In  order  to  keep  the  infant  or  young  child  in  good  physical  con- 
dition, one  free  evacuation  of  the  bowels  is  required  once  in  twenty- 
four  hours.  While  two  or  three  evacuations  daily  in  a  nursing  or 
bottle  baby  may  be  desirable,  this  number  is  not  absolutely  necessary. 
When  there  are  more  than  four  passages  in  twenty-four  hours,  it 
means  that  something  is  wrong  with  the  intestinal  tract.  This, 
however,  may  not  be  of  such  a  nature  as  to  require  radical  means  for 
its  correction.  Thus,  in  many  nursing  babies  who  are  supplied  with 
a  high-fat  breast-milk  there  may  be  several  thin  greenish  stools  in 
twenty-four  hours,  in  spite  of  which  conditio!;  the  child  thrives 
satisfactorily.  It  is  well  in  these  cases  to  attempt  to  reduce  the 
fat  in  the  breast-milk  by  measures  suggested  elsewhere,  but  by  no 
means  should  the  nursing  be  interdicted  if  the  baby  is  making  a 
reasonable  gain  in  weight.  The  proof  of  successful  nursing  is  a 
thriving  child,  not  the  character  of  the  stool.  The  habit  of  an 
evacuation  at  a  certain  time  each  day  is  one  of  the  most  important 
preventives  of  constipation  in  an  infant.  There  is  a  standing  order 
in  every  household  where  I  have  such  a  patient,  to  the  effect  that 
the  child  is  never  to  be  put  to  bed  for  the  night  unless  the  bowels 
have  moved  during  the  preceding  twentv-four  hours.  Either  a 
simple  soap-and-water  enema  or  a  small  glycerin  suppository  is 
employed.  The  enema  is  preferred,  from  four  to  eight  ounces  of 
the  soap- water  being  used.  The  suppository  is  used  only  when,  for 
any  good  reason,  the  enema  is  not  available.  Placing  the  child 
at  stool  immediately  after  the  morning  bottle  is  one  of  the  means 


BOWEL   FUNCTION  1 67 

of  establishing  the  habit  of  an  evacuation  at  a  definite  time  each 
day.  The  child  soon  appreciates  the  reason  for  this  position  and 
acts  accordingly.  This  practice  may  be  begun  when  the  child  is 
five  or  six  months  of  age. 

Defective  Bowel  Evacuation. — Defective  bowel  evacuation  in 
infants  and  young  children  is  a  form  of  constipation  very  apt  to  be 
overlooked,  and  for  this  reason  it  is  put  under  an  independent  head- 
ing. As  long  as  an  evacuation  takes  place  daily  it  is  supposed  to  be 
sufficient.  Even  though  a  passage  takes  place  daily  and  voluntarily, 
if  it  is  dry  and  comes  away  in  pieces  or  in  hard  balls,  or  is  firmly 
formed  without  the  moist  surfaces  caused  by  the  presence  of  mucus 
and  water,  it  is  practically  certain  that  the  evacuation  is  not  com- 
plete and  that  fecal  matter  is  retained  in  the  intestine.  This  may 
occur  at  any  age,  and  when  the  condition  persists,  there  results, 
oftentimes,  an  intestinal  toxemia,  with  the  manifestations  referred 
to  under  that  caption  (page  191).  The  same  methods  of  treatment 
are  to  be  followed  as  suggested  in  the  preceding  chapters  on  consti- 
pation for  the  various  ages  of  infancy  and  childhood.  Usually, 
however,  in  this  type  of  constipation,  dietetic  measures  are  sufficient. 

Constipation  in  Nurslings. — There  are  many  nursing  infants, 
who  are  thriving  and  well  in  every  respect,  except  that  they  are  con- 
stipated. There  is  greatly  delayed  or  no  bowel  evacuation  without 
aid.  Our  first  step  in  the  management  of  these  cases  is  to  examine 
into  the  daily  life  and  habits  of  the  mother.  A  factor  in  the  etiology 
of  constipation  in  the  infant  is  constipation  in  the  mother,  which, 
if  relieved  by  diet  or  medication,  will  often  relieve  the  child;  or  if 
not  relieved,  the  subsequent  treatment  directed  toward  the  child 
will  be  much  less  effective.  Nursing  women  who  drink  a  great 
Meal  of  tea  are  apt  to  be  constipated,  and  their  infants  likewise. 
The  nursHngs  of  mothers  who  lead  indolent  lives,  taking  but  httle 
exercise,  are  likewise  sufferers  from  constipation. 

Treatment  of  the  Mother. — Errors  in  the  mother's  diet  and  habits 
of  life  must  be  corrected  and  the  scheme  carried  out  which  is  re- 
commended on  page  64. 

Having  established  a  proper  regime  for  the  mother,  the  breast- 
milk  should  be  examined  (page  76).  While  high  proteid  may  mean 
constipation,  it  is  rare,  in  my  observation,  to  find  this  a  cause.  Low 
fat,  from  1.5  to  2.5  percent,  with  normal  proteid  is  much  oftener 
found  to  be  present  in  these  cases. 

Often  in  such  cases  the  fat  in  the  mother's  milk  may  be  increased 
by  the  use  of  some  form  of  alcohol,  given  with  the  meals.     Wine, 
beer,  ale,  porter,  or  the  liquid  malt  preparations  ma}'^  be  given,  the  . 
mother  being  allowed  to  make  her  own  selection  according  to  her 
taste.     The  free  eating  of  red  meats  also  increases  the  fat  in  the  milk. 

Several  years  ago  a  series  of  observations  were  made  in  the  New 
York  Infant  Asylum  relating  to  the  effects  of  diet  on  breast-milk. 


1 68  G ASTRO-ENTERIC   DISEASES 

It  was  found  that  in  some  cases  the  fat  could  be  increased  from  i  to 
2  percent  b}^  the  addition  of  alcohol  to  the  mother's  diet.  The 
value  of  the  various  galactagogs  on  the  market  depends,  in  all 
probability,  upon  the  alcohol  which  they  contain. 

Treatment  of  the  Child. — From  the  standpoint  of  nutrition  and 
as  a  laxative,  a  A'^aluable  addition  to  the  diet  of  the  constipated 
breast-fed  infant,  when  the  mother's  milk  is  found  weak  in  fat,  is 
cow's-milk  cream,  one-half  to  one  teaspoonful  being  given  before 
every  second  nursing  or  before  every  nursing,  according  to  the 
age  of  the  child  and  his  capacity  for  fat  digestion.  Children  during 
the  early  months  of  life  take  pure  cod-liver  oil  readily,  which,  like 
cream,  may  serve  the  double  function  of  a  food  and  a  laxative. 
Establishing  by  careful  instruction  the  habit  of  an  evacuation  of  the 
bowels  at  a  certain  time  every  day,  is  a  valuable  measure  in  all 
children. 

Drugs. — Drug-giving  is  rarely  necessary  in  young  children  and 
should  be  resorted  to  only  when  other  measures  fail.  In  case  drugs 
are  necessary,  those  most  useful  ordinarily  are  the  preparations  of 
cascara  sagrada.  The  aromatic  fluid  extract  (Parke,  Davis  &  Co.) 
is  palatable  and  may  be  given  in  sufficient  doses  to  be  effective  once 
or  twice  daily.  The  milk  of  magnesia  with  equal  parts  of  the 
aromatic  syrup  of  rhubarb,  given  in  doses  of  from  one  to  three  tea- 
spoonfuls  daily,  is  an  agreeable  and  usually  an  effective  combina- 
tion. 

Enemata  and  Suppositories. — The  use  of  water  enemata  and  sup- 
positories is  not  to  be  advised  as  a  routine  measure.  The  habit  of 
depending  upon  them  is  readily  established,  the  parts  by  their  fre- 
quent use  become  insensitive  to  stimulation,  and  in  a  few  weeks 
they  fail  to  act.  I  have  had  many  mothers  come  to  me  for  the  first 
time  in  great  distress  when  this  stage  was  reached.  When  the 
stool  is  dry  and  hard  and  is  passed  with  difficulty,  the  injection  of 
two  ounces  of  warm  sweet  oil  at  bedtime  is  of  advantage.  This  is 
not  with  the  idea  of  producing  an  immediate  evacuation,  but  rather 
to  act  as  a  lubricant  for  the  evacuation  expected  the  following 
morning. 

Malted  Foods. — It  is  elsewhere  advised  that  the  nursing  baby  be 
given  one  bottle-feeding  daily.  The  malted  proprietary  foods  are 
distinctly  laxative  to  many  children.  It  has  long  been  my  custom, 
when  in  a  nursing  infant  a  condition  of  constipation  exists  which 
is  not  relieved  by  careful  regulation  of  the  mother's  diet,  to  pre- 
scribe one  feeding  of  malted  milk  daily,  the  food  being  given  usually 
in  the  strength  of  one  teaspoonful  to  an  ounce  of  water.  Some 
children  will  not  take  it  in  this  strength,  as  the  sweet  taste  is  objec- 
tionable. In  such  cases  it  may  be  given  weaker  at  the  beginning, 
or  it  ma}^  be  given  in  a  milk  mixture  suitable  to  the  age  of  the 
child;  but  when  used  in  this  way,  there  should  be  no  addition  of 


BOWEL   FUNCTION  1 69 

sugar.  Malted  milk  or  Mellin's  food  may  be  used  in  a  quantity 
equal  to  that  of  the  sugar. 

Massage  is  a  most  valuable  means  of  treatment  in  the  constipation 
of  older  children,  but  in  nurslings  and  in  the  bottle-fed  of  tender  age, 
on  account  of  the  restlessness  and  crying,  it  is  not  generally  practi- 
cable, and  to  be  effective  it  requires  that  it  should  be  given  only  by 
those  skilled  in  its  use;  therefore,  unless  the  case  is  an  extreme  one, 
and  all  other  measures  have  failed,  massage  is  not  to  be  employed 
in  the  very  young.  I  have  never  seen  any  benefit  from  the  abdominal 
manipulations  attempted  by  the  mother  or  nurse. 

Treatment  of  Constipation  in  the  Bottle-fed. — In  the  bottle-fed, 
inactivity  of  the  bowel  is  more  easily  managed  than  in  the  nurs- 
ling, because  in  the  former  we  are  in  a  better  position  to  adapt 
the  food  to  the  child's  digestive  peculiarities.  As  a  rule,  consti- 
pated bottle  babies  should  have  a  reasonably  high  fat — 3.5  to  4 
percent — and  sugar  up  to  at  least  7  percent,  but,  as  with  all  rules, 
this  one  is  open  to  exceptions,  a  few  of  the  most  obstinate  cases 
of  constipation  that  have  come  under  my  care  being  those  fed  on 
a  very  high  fat,  the  constipation  being  due  to  fat  indigestion.  It 
is  extremely  rare  to  find  a  child  who  can  digest,  day  after  day,  a 
milk  mixture  containing  more  than  4  percent  of  cow's-milk  fat. 

The  Proteid. — Cow's-milk  casein  is  probably  the  most  fruitful 
factor  in  causing  constipation  in  bottle-fed  babies,  nevertheless 
it  is  necessary  for  the  child's  nutrition.  A  considerable  reduction, 
such  as  may  be  obtained  by  giving  a  mixture  of  cream,  sugar,  and 
water,  may  relieve  the  constipation,  but  the  child  suffers  from  a  nu- 
tritional standpoint,  and  instead  of  having  a  constipated  baby  to 
deal  with  we  have  a  rachitic  one,  which  is  much  worse.  In  not 
a  few  instances  I  have  seen  malnutrition  result  from  cutting  down 
the  proteid,  in  the  effort  to  relieve  constipation. 

The  child's  growth  and  development  should  jnost  concern  us  in 
our  relations  with  him,  and  this  should  never  be  subservient  to  any- 
thing else.  A  child  under  six  months  of  age  will  not  thrive  satis- 
factorily on  less  than  i  percent  of  proteid  as  found  in  cow's  milk. 
He  is  entitled  to  at  least  1.5  percent,  and  thrives  best  when  this 
amount  is  given.  The  relief  of  the  constipation  can  in  almost 
every  instance  be  accomplished  by  other  means  than  a  too  great 
reduction  in  the  casein — the  most  nutritive  element  in  the  infant's 
food. 

Milk  given  constipated  infants  should  always  be  raw,  as  cook- 
ing increases  its  constipating  tendency. 

Laxative  Agents  in  the  Food. — ^The  simplest  means  of  treating 
constipation  in  the  bottle-fed  is  by  the  employment  of  a  laxative 
agent  in  the  food,  and  when  such  an  agent  adds  to  its  nutritive 
value,  it  serves  a  double  purpose.  Instead  of  using  water  as  a 
diluent,  oatmeal-water  No.   i    (see  Formulary)  may  be  employed. 


I70  GASTROENTERIC    DISEASES 

The  malted  proprietary  foods,  such  as  MelUn's  food,  and  malted  milk 
are  laxative  to  most  children.  Mellin's  food  is  composed  largely 
of  sugar,  and  therefore  it  may  be  used  in  place  of  sugar-of-milk  or 
cane-sugar  in  the  food  mixture,  and  has  thus  served  me  well  in  re- 
lieving constipation.  In  some  instances  I  substitute  a  feeding  of 
malted  milk  once  daily  for  the  regular  milk  food,  with  from  four 
to  eight  ounces  of  water,  the  quantity  and  strength  depending, 
of  course,  upon  the  age  of  the  child. 

Drugs  and  Local  Measures. — Dietetic  measures  should  always  be 
tried  before  drugs  are  resorted  to,  for  when  drugs  are  used,  we  have 
to  give  them  in  constantly  increasing  doses,  and  they  soon  become 
ineffective.  One  or  two  teaspoonfuls  of  milk  of  magnesia  in  one 
bottle  daily  may  be  recommended  as  a  temporary  expedient  in  some 
cases.  The  magnesia  may  be  of  service  until  the  condition  is  con- 
trolled by  the  diet.  The  aromatic  fluidextract  of  cascara  sagrada, 
in  doses  of  from  fifteen  drops  to  one  dram,  may  be  tried  if  success 
does  not  follow  the  use  of  the  magnesia. 

Water  enemata  and  suppositories  should  be  used  only  as  tem- 
porary measures.  Orange-juice,  two  teaspoonfuls,  twice  daily  be- 
fore feedings,  is  worthy  of  trial  and  is  of  antiscorbutic  value  in 
children  artificially  fed.  Sweet  oil  and  the  pure  cod-liver  oil  may 
also  be  used  in  doses  of  from  fifteen  drops  to  a  dram,  three  times 
daily  after  feedings  if  the  patient  shows  a  tendency  to  rachitis  or  to 
general  malnutrition.  In  the  use  of  the  oils,  we  have  their  beneficial 
effects  not  only  as  laxatives  but  also  as  aids  to  nutrition. 

Oil  Injections. — In  case  the  stool  remains  hard  and  dry,  in  spite 
of  the  above  suggestions,  an  injection  of  two  ounces  of  warm  sweet 
oil  (page  173)  may  be  given  at  bedtime  every  night,  not  with  a 
view  of  inducing  a  passage  at  the  time,  but  as  a  lubricant  to  the 
parts  and  as  a  solvent  of  the  hard  fecal  masses. 

Constipation  in  Older  ChMr^n.— Etiology. — Probably  the  most 
potent  dietetic  factor  in  causing  constipation  in  children  of  the 
"runabout"  age  is  the  use  of  full  milk.  Particularly  is  this  apt  to 
be  the  case  if  the  milk  is  boiled.  Constipation  may  be  occasioned, 
further,  by  a  too  great  concentration  of  the  food,  insufficient  volume 
being  furnished  to  produce  copious  evacuations. 

Local  Treatment. — In  a  great  majority  of  children  the  freer  feed- 
ing following  weaning  from  the  breast  and  bottle  relieves  the  ten- 
dency to  constipation  from  which  many  children  suffer  during  the 
earlier  months  of  life.  In  a  small  percentage  of  cases,  however, 
such  relief  is  not  furnished,  and  the  child  will  require  the  attention  of 
a  physician.  In  making  the  physical  examination  of  a  case  of  this 
nature,  special  care  should  be  directed  toward  the  examination  of 
the  rectum,  in  order  that  local  causes,  such  as  fissures  or  hemorrhoids, 
may  be  ehminated.  If  fissures  are  present,  the  child  will  use  every 
effort  to  prevent  a  bowel  movement. 


BOWEL   FUNCTION  171 

Regular  Habits. — As  a  rule,  children  who  are  presented  for  treat- 
ment after  the  second  year  have  not  had  the  benefit  of  carefully  reg- 
ulated habits  of  life,  so  that  our  first  step  is  to  correct  bad  habits, 
that  may  have  a  bearing  on  the  condition,  and  to  teach  good  ones. 
The  desirability  of  establishing  in  the  child  the  habit  of  a  bowel 
evacuation  at  a  certain  definite  time  every  day  should  be  impressed 
upon  the  mother  or  nurse.  In  order  to  bring  this  about,  an  attempt 
should  be  made  to  induce  a  movement  of  the  bowels  by  voluntary 
effort  every  morning  after  breakfast.  Not  a  few  children  are  too 
busy,  too  active  in  their  play,  to  respond  to  the  call  of  nature  when 
it  comes,  and  if  it  can  be  repressed,  they  say  nothing  about  it.  If 
a  certain  time  of  the  day  is  selected  for  the  evacuation,  and  if  they 
have  to  remain  at  stool  until  it  occurs  naturally,  or  by  means  of  a 
suppository  after  fifteen  minutes  have  elapsed,  much  is  accom- 
pHshed  by  this  means  alone  toward  establishing  the  habit. 

Diet. — Ultimately,  much  may  be  accomplished  in  these  cases  by 
diet.  Foods  other  than  milk  may  now  be  given,  so  that  a  high- 
proteid  milk,  a  milk  rich  in  casein,  is  not  necessary.  As  it  is  de- 
sirable to  continue  the  use  of  milk  at  this  age,  the  following  com- 
bination of  top  milk  and  water  may  be  used  instead  of  full  milk.  A 
quart  bottle  of  cow's  milk  is  allowed  to  stand  at  a  temperature  of  be- 
tween 40°  and  50°  F.  for  five  hours,  when  the  top  ten  ounces  are 
removed.  The  skimming  is  best  done  with  a  Chapin  dipper  (see 
Fig.  10,  page  83).  The  ten  ounces  of  top  milk  are  mixed  with 
twenty  ounces  of  oatmeal  gruel  or  plain  boiled  water  and  given  as  a 
drink. 

The  giving  of  high-fat  mixtures  in  constipation  is  sometimes 
overdone  even  in  older  children.  We  seldom  find  a  child  five  years 
of  age  who  can  digest,  day  after  day,  a  milk  or  cream  mixture  con- 
taining over  4  percent  of  fat.  Attacks  of  acute  indigestion  and 
faulty  nutrition  are  very  apt  to  result  when  too  high  a  fat  is  persist- 
ently given.  In  not  a  few  instances  I  have  seen  grave  malnutrition 
result  from  an  attempt  to  reheve  the  constipation  by  high-fat  feeding. 
It  must  also  be  remembered  that  high-fat  mixtures  may  produce 
constipation  in  children  of  any  age,  hard,  very  hght  colored,  usually 
foul-smelhng  stools  resulting.  By  using  the  top  milk,  diluted,  we 
give  a  sufficient  amount  of  fat  and  relieve  the  constipation  by  re- 
moving a  considerable  percentage  of  the  casein,  the  usual  constipat- 
ing element,  the  percentage  of  which  in  the  thirty  ounces  of  food, 
above  referred  to,  is  but  one-third  that  in  full  milk.  Of  course,  the 
nutritive  value  of  the  dilution  is  less  than  that  of  full  milk,  but  the 
child  is  now  at  an  age  when  proteid  can  be  given  in  other  forms 
than  in  the  milk. 

Diet  after  the  Second  Year. — White  wheaten  bread,  wheaten 
flour  crackers,  with  full  raw  milk  should  form  no  part  of  the 
dietary  of  our  patients.     It  is  best  to  give  to  parents  of  children  we 


172  GASTRO-ENTERIC   DISEASES 

are  treating  for  constipation  a  list  of  permissible  articles  of  food 
from  which  they  are  instructed  to  make  up  suitable  meals.  The 
following  articles  of  diet  may  be  allowed  children  after  the  second 
year: 

Animal  broths,  purees  of  Hashed  chicken. 

peas,  beans,  and  lentils.  Lamb  chops. 

Rare  roast  beef.  Soft-boiled  eggs. 
Rare  steak. 

Green  vegetables,  such  as : 

Peas.  Asparagus. 

String-beans.  Strained  stewed  tomatoes. 

Spinach.  Cauliflower,  masted. 

■  Cereals,  as  follows  (each  cooked  for  three  hours) : 
Cracked  wheat.  Hominy. 

Oatmeal.  Cornmeal. 

The  cereals  may  be  served  with  a  small  amount  of  milk  and  sugar,  or 
better  with  butter  and  sugar. 

Bran  biscuits.  Zwieback. 

Oatmeal  crackers.  Whole  wheaten  bread. 

Graham  wafers. 

Desserts : 

Stewed  or  baked  apple.  Cornstarch. 

Stewed  prunes.  Plain  vanilla  ice-cream. 

Custard.  Junket. 

Malted  milk  may  be  given  as  a  drink.  Six  teaspoonfuls  of  malted 
milk  in  eight  ounces  of  hot  water  may  be  given  once  or  twice  daily. 
An  agreeable  change  in  taste  of  the  malted  milk  may  be  made  by  the 
addition  of  a  teaspoonful  of  cocoa.  If  milk  is  given  as  a  drink,  the 
top  ten  ounces  from  a  quart  bottle  should  be  used  as  described 
above,  mixed  with  twenty  ounces  of  boiled  water. 

A  child  in  fair  health  after  the  second  year  usually  thrives  best 
on  three  meals  daily.  If  he  is  delicate  or  if  a  fourth  meal  does  not 
interfere  with  the  appetite  for  the  other  meals,  it  may  be  allowed. 
The  extra  meal,  however,  should  be  light,  and  is  best  given  at  from 
2  to  3  o'clock  in  the  afternoon.  For  a  child  suffering  from  consti- 
pation, it  may  consist  of  a  cup  of  broth  with  a  graham  or  oatmeal 
cracker.  Orange-juice  or  a  scraped  raw  apple  may  also  be  given  at 
this  time.  When  only  three  meals  are  allowed,  the  orange-juice  or 
scraped  apple  should  be  given  in  the  afternoon  about  two  hours 
before  the  evening  meal.  The  giving  of  the  fruit-juice  or  the  apple 
on  an  empty  stomach  is  a  valuable  aid  in  relieving  chronic  constipa- 


BOWElv   FUNCTION 


'73 


tion.     These  patients  should  also  be  encouraged  to  eat  plenty  of 
butter. 

Treatment  after  the  Fifth  Year. — Permissible  articles  for  a  child 
of  from  five  to  ten  years  of  age  include  those  mentioned  above,  with 
the  addition  of  dates,  figs,  raw  and  cooked  fruits,  baked  and  stewed 
potatoes,  meats,  baked  and  broiled  poultry,  and  fish.  The  latter 
should  be  served  plain  without  sauce.  Plain  puddings  may  also  be 
allowed.  One  or  two  raw  apples,  an  orange  or  a  large  peach  or 
pear,  should  be  given  every  afternoon.  It  is  not  promised  that  in 
a  case  of  chronic  constipation  the  above  diet  will  at  once  produce 
normal  bowel  movements.  The  diet  must  be  continued  for  weeks 
in  some  cases  before  marked  benefit  will  be  observed;  in  others 
the  results  are  very  prompt  and  satisfactory.  Enemata  and  sup- 
positories will  be  necessary  at  first  until  the  habit  of  an  evacuation 
of  the  bowels  at  a  certain  time  every  day  is  established. 

Drugs. — Drugs  also  may  be  of  temporary  service.  The  cascara 
preparations  are  the  best  that  we  possess  for  this  condition.  If  the 
child  can  swallow  a  pill  or  a  tablet,  the  drug  may  be  given  in  this  form. 
The  one-grain  tablets  of  cascara  may  be  ordered  and  the  nurse  in- 
structed to  give  from  one  to  three  or  four  at  bedtime.  If  the  drug 
has  been  properly  prepared  from  the  well-seasoned  bark,  with  a  rea- 
sonable dose,  there  will  be  no  griping,  and  the  amount  given  on 
succeeding  nights  may  be  diminished  instead  of  increased,  as  is 
often  necessary  with  many  other  laxatives.  Its  use  should  not  be 
continued  longer  than  two  weeks.  If  the  daily  evacuation  habit  is 
not  established  at  that  time,  it  will  not  be  formed  by  further  drug- 
ging. If  the  pill  or  tablet  cannot  be  swallowed,  then  the  aromatic 
fluidextract  of  cascara  in  doses  of  from  one-half  dram  to  one  dram 
may  be  given.  Castor  oil,  calomel,  or  podophylHn  should  never  be 
given  without  other  indications  than  simple  constipation.  In  the 
cases  in  which  the  stools  are  soft  when  passed,  but  difficult  of  pass- 
age because  of  deficient  peristalsis,  the  tinctures  of  nux  vomica  and 
belladonna  may  be  given  with  benefit,  if  continued  for  a  considerable 
time.  A  child  three  years  of  age  ma)^  be  given  three  drops  of  the 
tincture  of  nux  vomica  and  two  drops  of  the  tincture  of  belladonna 
three  times  daily  in  pill,  capsule,  or  liquid  form.  The  constipation 
which  accompanies  mucous  colitis  is  referred  to  under  that  heading. 

Treatment  of  Obstinate  Constipation. — Despite  both  diet  and 
drugs,  we  meet  at  infrequent  intervals  cases  which,  without  struc- 
tural deformity,  resist  our  every  effort.  Drugs,  attempts  at  habit- 
forming,  and  diet  have  been  used  and  failed  until  only  the  most 
radical  measures  along  these  lines  furnish  relief.  In  such  cases  of 
obstinate  constipation,  I  use  the  following  means  of  management. 
Laxative  drugs  are  not  given. 

Diet. — Milk  and  cream  are  prohibited  except  in  sufficient  amount 
to  make  the  morning  and  evening  cereal  palatable.     For  this  purpose 


174  G ASTRO- ENTERIC   DISEASES 

not  over  two  ounces  of  milk  are  needed.  I  prefer  that  cereals  be 
taken  with  butter  and  sugar.  Aside  from  practically  cutting  ofiF  milk 
from  the  diet,  the  dietetic  measures  are  the  same  as  mentioned  above. 
Oil  Injections. — For  this  purpose  a  soft-bulb  syringe  of  four 
ounces  capacity  is  ordered.  Over  the  hard-rubber  tip  is  placed  a 
small  sized  adult  rectal  tube  or  a  No.  18  American  catheter.  The 
catheter  or  tube  is  cut  so  that  but  nine  inches  remain  for  use.  The 
cut  end  is  forced  over  the  small  hard-rubber  tip  of  the  syringe 
(Fig.  19).  A  fountain  syringe  is  impracticable  for  this  purpose, 
as  it  is  soon  destroyed  by  the  oil  and  rendered  unfit  for  use.  Be- 
sides, sufficient  pressure  is  not  produced  to  force  the  oil  into  the 
gut  even  with  a  high  elevation  of  the  bag.     The  child  is  placed  on  his 

back  or  on  his  left  side,  preferably  in 
.^  the   Sims   position.      The   syringe   is 

\.^  filled    with    oil,    the    tube    is    lubri- 


%»^,^^fc.  Fig.  19.— Bulb  Syringe  and  Cathethr 

■^'^S^j^^  FOR  Oil  Injection. 

cated,  and  passed  through  the  rectum  on  into  the  descending 
colon.  When  it  has  been  passed  to  the  full  nine  inches,  as  may 
readily  be  done  with  a  little  practice,  the  syringe  is  emptied 
and  the  tube  withdrawn.  The  irrigation  should  be  given  after 
the  child  has  been  placed  in  bed  for  the  night.  It  is  our  ob- 
ject to  have  the  oil  retained  during  the  night.  If  a  passage  of 
the  bowels  is  produced  at  the  time,  or  if  the  oil  leaks  out  during  the 
night,  a  smaller  quantity  should  be  used.  In  some  of  my  patients 
I  have  been  able  to  use  but  one  ounce.  In  very  few,  indeed,  does 
it  cause  an  evacuation  at  the  time.  If  there  is  a  tendency  to  leakage 
a  napkin  should  be  worn  to  avoid  soiling  the  bed-linen.  If  the  oil 
is  simply  placed  beyond  the  internal  sphincter,  it  will  rarely  be 
retained  during  the  night,  or  if  retained,  the  results  are  by  no  means 
as  good  as  when  it  is  placed  in  the  descending  colon.     The  following 


BOWEL    FUNCTION  I75 

morning,  after  breakfast,  the  child  is  placed  on  the  vessel  and  kept 
there  until  a  bowel  movement  results  or  until  fifteen  minutes  have 
elapsed.  In  a  great  many  cases  in  which  the  constipation  has  been 
obstinate  for  months,  the  bowel  will  at  once  be  evacuated.  When 
this  does  not  occur  in  fifteen  minutes,  a  glycerin  suppository  is  in- 
serted, which  invariably  produces  an  evacuation.  This  use  of  the 
suppository,  according  to  my  observation,  can  usually  be  dispensed 
with  in  a  very  few  days;  the  use  of  the  oil,  however,  may  have  to  be 
continued  for  several  weeks.  When  the  child  has  had  the  oil  nightly 
and  an  evacuation  the  next  morning  without  assistance  for  two 
weeks,  I  direct  that  the  oil  be  omitted  for  a  night  and  the  effect  noted. 
If  the  usual  passage  occurs  after  breakfast,  the  oil  is  given  for  five 
nights  and  then  again  omitted.  If  the  case  progresses  satisfactorily 
the  use  of  the  oil  is  gradually  omitted,  being  given  at  first  every 
second  night,  then  every  third,  fourth,  or  fifth  night,  etc.  A  con- 
siderable number  of  cases  have  been  completely  relieved  in  two 
months.  In  the  event  of  no  passage  following  the  omission  of  the 
oil,  its  use  is  continued  for  two  weeks  longer,  when  it  is  again  omitted 
for  a  night.     To  illustrate  this  point  the  following  case  is  cited : 

Illustrative  Case. — A  bo}^  three  years  of  age  had  never  had  a 
bowel  evacuation  without  drugs,  soap  enemas,  or  suppositories  since 
birth,  and  finally  these  were  no  longer  effective.  The  mother, 
thoroughly  frightened,  brought  the  child  to  me.  Eight  months  of 
diet  and  the  use  of  the  oil  were  required  before  he  was  entirely 
well.  It  is  now  three  months  since  the  local  treatment  was  dis- 
continued and  the  bowel  function  remains  normal. 

The  diet  with  the  absence  of  milk  must  be  continued  for 
months  after  the  patient  is  apparently  well,  and  he  must  not  be 
allowed  to  pass  a  single  morning  without  an  evacuation  at  the 
usual  time.  In  assuming  the  management  of  one  of  these  cases 
I  explain  to  the  mother  or  nurse  that  the  treatment  is  not 
pleasant  for  the  child  or  the  attendant,  and  that  it  may  have  to  be 
persisted  in  for  weeks,  and  unless  she  is  willing  to  carry  it  out  to  the 
end,  it  would  better  not  be  undertaken.  I  assure  her,  however, 
that  with  her  cooperation,  which  is  usually  readily  given,  the  child 
will  make  a  complete  recovery.  Cases  that  are  slow  in  responding 
to  treatment,  I  usually  give  the  additional  advantage  of  abdominal 
massage  from  twenty  minutes  to  one-half  hour,  before  the  child  is 
placed  at  stool.  The  massage  should  be  practised  by  one  skilled 
in  the  work. 

The  above  local  measures  apply  particularly  to  children  after 
the  eighteenth  month.  They  may  be  used  earlier,  however,  following 
out  the  diet  along  the  lines  laid  down  for  bottle-fed  children  who 
suffer  from  constipation.  In  very  young  children  a  smaller  amount 
of  oil  should  be  used,  never  more  than  two  ounces,  usually  one 
ounce  is  all  that  is  required.  When  the  oil  treatment  is  under  way, 
whatever  the  age  of  the  patient,  laxative  drugs  should  not  be  given. 


176  GASTRO-ENTERIC    DISEASES 


VOMITING 

While  vomiting  does  not  constitute  a  disease  in  itself,  it  is  a 
condition  of  such  frequency  in  children,  and  occurs  in  such  widely 
varying  circumstances,  that  any  work  relating  to  diseases  of  children 
would  be  incomplete  without  its  consideration. 

The  most  frequent  causes  of  vomiting  depend  solely  upon  the 
functions  of  the  stomach.  When  the  stomach  is  overfilled,  vomiting 
may  result.  '  When  substances  sufficiently  irritating  come  in  contact 
with  its  Hning  mucous  membrane,  whether  they  are  swallowed  as 
such  or  whether  produced  by  some  process  of  fermentation  or  by 
some  other  change  in  the  stomach  contents,  they  are  ejected.  When 
there  is  an  involvement  of  an  inflammatory  nature  of  the  mucous 
membrane  of  the  stomach,  whether  acute  or  chronic  in  character, 
the  stomach  becomes  intolerant  of  the  blandest  of  fluids.  Another 
condition  involving  the  structure  of  the  stomach,  but  only  occasionally 
seen  in  children,  is  ulceration,  which  is  usually  multiple.  I  have 
made  autopsies  upon  four  such  cases.  In  them,  vomiting  was  the 
prominent,  in  fact  the  only,  symptom. 

Dilatation  of  the  Stomach. — In  this  condition  the  food  does  not 
pass  into  the  intestine  but  remains  in  the  stomach  and  undergoes 
changes  which  produce  sufficient  irritation  to  cause  vomiting. 

Pyloric  Stenosis. — In  pyloric  stenosis  the  food  is  prevented  by 
the  narrow  pyloric  opening  from  passing  into  the  intestine;  one 
feeding  follows  another,  the  stomach  becomes  overloaded,  and,  b}' 
reason  of  fermentative  change  in  the  residue,  sufficient  irritation 
is  produced,  in  connection  with  the  spasmodic  contractions  of  the 
stomach  peculiar  to  the  condition,  to  induce  vomiting. 

Causes  Remote  from  the  Stomach .^ — In  intestinal  obstruction, 
whether  due  to  intussusception,  volvulus,  peritonitis,  or  impacted 
feces,  vomiting  is  an  invariable  accompaniment,  continuing  at  irreg- 
ular intervals  until  the  obstruction  is  relieved  or  until  the  child  dies. 

The  Acute  Infectious  Diseases. — The  exanthemata  and  lobar 
pneumonia  are  very  apt  to  be  ushered  in  by  vomiting  if  the  onset 
is  sudden  and  intense.  In  appendicitis  in  children,  vomiting  is 
usuall}^  one  of  the  early  symptoms;  so  also  in  the  different  forms  of 
meningitis,  vomiting  is  often  an  early  symptom,  and  may  continue 
persistently  during  the  first  few  days  of  the  illness.  In  nephritis, 
with  uremia,  vomiting  is  usually  present.  Vomiting  may  be  caused 
by  fright,  by  shock,  or  by  a  strain  of  any  nature,  as  in  whooping- 
cough,  or  it  may  be  of  a  purely  nervous  origin. 

Illustrative  Case. — A  few  years  ago  I  had  a  most  unusual  and  in- 
teresting case.  The  patient  was  a  girl  four  years  old,  pale  and  thin. 
The  history  was  that  of  vomiting  for  more  than  a  year,  which  had 
begun  with  rather  a  protracted,  badly  managed  attack  of  indigestion. 
At  first  there  would  be  but  one  or  two  attacks  a  day.     lyater  they 


ACUTE    GASTRITIS    AND    ACUTE   GASTRIC    INDIGESTION  1 77 

became  more  frequent,  and  for  a  few  weeks  before  coming  to  me,  the 
vomiting  had  occurred  at  the  table  with  nearly  every  meal,  before 
the  meal  was  completed.  The  mother  was  most  anxious  and  appre- 
hensive regarding  the  child's  condition.  She  was  always  with  her, 
always  fed  her,  and  always  worried  constantly  throughout  the  meal, 
fearing  an  attack  of  vomiting.  Using  the  most  thorough  means  of  ex- 
amination of  the  stomach,  I  failed  to  find  anything  wrong  with  it. 
After  observing  the  case  for  some  days  it  occurred  to  me  that  the 
presence  of  the  apprehensive  mother,  in  whose  mind  the  condition 
of  the  child  and  the  vomiting  were  uppermost,  might  be  a  factor  in 
causing  the  vomiting.  I  accordingly  directed  that  the  child  take  her 
meals  in  the  kitchen  with  the  maid,  and  that  the  matter  of 
vomiting  should  not  be  mentioned.  The  mother  was  directed  not 
to  come  in  contact  with  the  child  in  any  way  during  the  meal.  I 
was  much  gratified  and  not  a  little  surprised  when  the  vomiting 
promptly  ceased.  After  a  few  months  of  dining  with  the  maid  the 
latter  was  taken  ill,  and  the  mother  for  one  day  attended  to  the 
feeding.     Again  the  child  vomited  as  before. 

The  management  of  the  different  types  of  vomiting  will  be 
referred  to  in  the  consideration  of  the  various  diseases  with  which 
it- is  associated. 

ACUTE  GASTRITIS  AND  ACUTE  GASTRIC  INDIGESTION 

Not  a  little  confusion  exists  as  to  the  differentiation  of  acute 
gastritis  and  acute  gastric  indigestion.  Cases  of  gastric  indigestion 
are  often  diagnosed  as  gastritis.  In  fact,  acute  gastritis  in  children 
is  a  very  rare  condition,  while  acute  gastric  indigestion  is  very 
common.  Acute  gastritis  in  the  young  is  usually  due  to  the  ingestion 
of  drugs,  corrosive  or  irritant  in  character.  Food  given,  unsuitable 
in  character  or  quantity,  or  food  which  may  have  undergone  chemical 
or  bacterial  change,  may  produce  pronounced  vomiting,  usually 
transient  in  character.  Inflammation  of  the  mucous  membrane  of 
the  stomach  may  be  produced  in  this  way,  but  according  to  autopsy 
findings  it  is  most  unusual.  Acute  gastric  indigestion  is  manifested 
in  sudden  repeated  vomiting,  often  with  fever,  and  always  with 
prostration. 

Cases  of  persistent  vomiting  which  are  often  diagnosed  as  gas- 
tritis not  infrequently  prove  to  be  of  cerebral  or  uremic  origin,  or 
they  are  due  to  some  form  of  intestinal  obstruction. 

Autopsies  on  infants  dying  from  acute  gastro-enteric  diseases, 
such  as  cholera  infantum,  rarely  show  any  stomach  lesion,  although 
there  may  have  been  persistent  vomiting  for  two  or  three  days. 

Treatment. — A  high  enema  should  always  be  given  as  the  initial 
treatment  in  any  illness  of  any  nature  in  which  there  is  acute  vom- 
iting with  an  absence  of  free  bowel  action.  If  the  vomiting  is 
continued,  the  management  of  the  case,  regardless  of  the  exciting 


1 78  GASTRO-ENTERIC   DISEASES 

cause,  is  to  wash  out  the  stomach  at  least  once  and  to  give  no  food  by- 
mouth.  If  the  case  is  of  more  than  twelve  hours'  duration  in  infants 
and  twenty-four  hours'  in  older  children,  colon  flushings  should  be 
carried  out  to  supply  fluids  to  the  organism  (page  199). 

Diet. — After  twelve  or  twenty-four  hours'  abstinence  from  food, 
small  quantities  of  water  may  be  given  tentatively,  if  the  child 
craves  it,  or  some  very  weak  food.  Whey,  milk,  barley-water,  weak 
tea,  chicken  or  mutton  broth,  may  be  tried  in  teaspoonful  doses 
every  half  hour.  Usually  cold  foods  will  be  retained  better  than 
those  that  are  heated.  If  the  food  or  water  is  rejected  a  further 
stomach  rest  of  from  eight  to  twelve  hours  may  be  ordered,  before 
the  feeding  is  resumed. 

Treatment  of  Protracted  Cases. — In  the  protracted  cases  the 
stomach  should  be  washed,  at  least  once  daily,  with  a  5  percent 
solution  of  bicarbonate  of  soda.  It  is  never  wise,  in  the  event  of 
vomiting,  to  attempt  forced  feeding,  as  nothing  will  be  gained;  in 
fact,  the  vomiting  may  be  continued  indefinitely,  and  chronic  gastric 
indigestion  estabHshed,  as  a  result  of  injudicious  attempts  at  feeding. 
For  the  persistent  vomiting  of  infants,  gavage  (page  135)  may  also 
be  used.  I  have  employed  this  successfully  in  a  great  many  cases 
of  persistent  gastric  indigestion  with  vomiting.  A  food  which  is 
rejected  when  swallowed,  will  oftentimes  be  retained  when  put  into 
the  stomach  through  a  tube.  If  nourishment  cannot  be  retained 
after  thirty-six  hours,  when  given  by  the  natural  method  or  by 
gavage,  it  is  best  to  begin  feeding  by  the  bowel,  using  completely 
peptonized  milk,  at  intervals  of  from  six  to  eight  hours,  in  quantities 
of  from  two  to  four  ounces  for  young  infants  and  from  six  to  twelve 
ounces  for  children  from  eight  to  ten  years  of  age.  Applications  of 
heat  or  counter-irritation  over  the  stomach  area  have  been  of  very 
little  service.  I  have  used  mustard  leaves  from  time  to  time,  but 
have  never  been  impressed  with  their  value.  Drugs  were  better 
omitted.  I  have  treated  hundreds  of  these  cases  of  acute  indigestion 
with  different  means  of  medication,  including  calomel,  small  doses  of 
ipecac,  oxalate  of  cerium,  opium,  etc.,  and  have  been  far  more 
impressed  with  their  uselessness  than  with  their  beneficial  influence. 
Drugs  oftentimes  get  credit  to  which  they  are  not  entitled  for  the 
improvement  of  the  patient.  A  child  has  an  acute  attack  of  indiges- 
tion with  repeated  vomiting.  He  is,  perhaps,  given  an  enema,  his 
food  is  stopped,  a  certain  drug  is  given  in  small  quantities  of  water, 
and  he  recovers,  and  the  drug  gets  the  credit.  He  probably  would 
have  recovered  more  quickly  without  the  drug.  As  a  rule,  drugs, 
or  even  the  use  of  a  small  quantity  of  water,  when  given  early,  will 
prolong  the  attack. 

An  enema,  the  recumbent  position,  and  abstinence  from  food, 
with  fluids  such  as  normal  salt  solution,  or  nourishment  by  the 
bowel,  have  given  me  my  best  results.     When  the  child  craves  food, 


CHRONIC    GASTRIC    INDIGESTION;    CHRONIC   GASTRITIS  1 79 

and  asks  for  water  after  an  abstinence  of  several  hours,  it  may  be 
tried,  but  the  fact  that  he  asks  for  it  is  by  no  means  a  guarantee  that 
it  will  be  retained. 

Treatment  of  Persistent  Vomiting. — In  pronounced,  persistent 
vomiting,  morphin  hypodermatically  may  be  required.  The  morphin 
should  be  guarded  by  atropin  and  given  in  doses  of  -L  ^q  _i__  grain  for 
a  child  one  year  old,  to  y^  of  a  grain  for  a  child  of  from  eight  to 
twelve  years  old.  The  relation  of  the  dose  of  morphin  to  that  of 
the  atropin  should  be  as  i  to  2^^.  Thus,  a  child  who  is  given  3^^ 
grain  morphin  should  have  combined  with  it  -g^Q^  grain  atropin; 
with  ^ij  grain  morphin  there  should  be  ^j)^  grain  atropin. 

It  will  rarely  be  necessary  to  repeat  the  morphin  more  than  once, 
two  injections  being  given  at  intervals  of  from  four  to  six  hours. 
In  all  cases  the  usual  feedings  must  gradually  be  resumed.  After 
trying  different  foods  it  will  soon  be  learned  which  will  best  be  re- 
tained. 

CHRONIC  GASTRIC  INDIGESTION;  CHRONIC  GASTRITIS 

Chronic  gastritis  is  seen  most  frequently  in  comparatively  young 
children,  and  is  often  associated  with,  or  is  a  cause  of,  marasmus 
and  malnutrition.  Vomiting  and  regurgitation  of  food  are  the 
predominant  acute  manifestations  of  the  disorder.  The  condition 
is  almost  invariably  a  result  of  slight  but  persistent  errors  in  feed- 
ing— errors  too  small  to  make  the  child  violently  ill,  but  sufficient 
to  keep  the  stomach  in  a  constant  state  of   unrest. 

Treatment. — The  management  consists  in  daily  stomach-wash- 
ings, sometimes  for  a  long  period,  and  an  adaptation  of  the  food  to 
the  child's  digestive  capacity  (page  94).  'While  there  is  no  one  w^ay 
of  feeding  these  cases,  a  food  of  greatly  reduced  strength  must 
always  be  given,  particularly  when  cow's  milk  is  used.  As  a  rule, 
these  children  have  a  low-fat  capacity;  not  more  than  1.5  percent 
can  usually  be  taken.  Sugar  is  also  badly  borne  by  many  of  these 
infants  and  must  be  given  in  reduced  strength — from  3  to  4  percent 
only.  Usually  the  proteids  are  fairly  well  taken  care  of  if  the  func- 
tion of  the  stomach  is  not  compromised  by  too  much  fat  and  sugar. 
In  children  under  nine  months  of  age,  a  wet-nurse  may  help  solve 
the  problem.  In  beginning  with  the  wet-nurse,  however,  the  child 
should  not  be  allowed  to  get  over  one  or  two  ounces  at  a  nursing, 
lest  the  fat  in  the  milk  continue  the  trouble.  The  remainder  of 
the  feeding  is  given  by  the  bottle.  Granum-water  or  barley-water 
No.  I  (see  page  123)  may  be  used  in  quantity  sufficient  to  bring  up 
the  amount  to  the  number  of  ounces  required. 

Dilatation  of  the  stomach  is  usually  present  and  motor  inactivity 
necessitates  stomach-washing,  which  may  be  required  for  several 
months  at  gradually  increasing  intervals.  Details  of  the  treatment, 
which  are  largely  matters  of  feeding,  would  necessitate  a  repetition 


l8o  GASTRO-ENTERIC    DISEASES 

of  what  has  been  said  in  the  chapter  on  Malnutrition,  Marasmus, 
and  Food  Adaptation,  to  which  the  reader  is  referred. 

LAVAGE-STOMACH-WASHING 

To  Seibert,  of  New  York,  is  due  the  credit  of  first  caUing  attention 
in  this  country  to  the  value  of  stomach-washing.  Its  use  was  soon 
appreciated  by  pediatricians  generally,  and  at  the  present  time  it 
is  an  indispensable  therapeutic  measure  with  those  who  are  actively 
engaged  in  children's  hospitals,  in  out-patient  or  in  private  work 
among  children.  In  the  vomiting  of  children,  whether  due  to  an 
acute  gastro-enteric  infection,  a  chronic  indigestion,  or  a  subacute 
attack  of  chronic  gastritis,  it  is  equally  valuable.  The  dangers  of 
stomach- washing  can  be  said  to  be  practically  nil.  A  colleague  a 
few  years  ago,  while  washing  the  stomach  of  a  child  two  years  of  age, 
turned  away  for  a  moment,  when  suddenly  the  struggling  child  dis- 
connected the  tube  from  the  glass  connecting-rod  and  swallowed  it. 
Attempts  at  its  removal  through  the  bowel  were  unsuccessful; 
gastrostomy  was  performed,  the  tube  removed,  and  the  child  recov- 
ered. This  is  the  only  accident  of  any  kind  I  have  ever  known 
during  stomach-washing. 

The  Operation. — For  lavage,  the  child  is  easiest  handled  when  its 
arms  are  pinned  to  its  sides  by  a  towel  passing  around  the  body. 
It  may  rest  on  its  back  in  a  crib,  or  sit  upright  on  the  lap  of  the 
nurse  or  mother  (Fig.  20).  The  clean  left  index-finger  of  the  phy- 
sician is  placed  upon  the  base  of  the  patient's  tongue.  The  tube, 
moistened  with  the  fluid  to  be  used  in  the  washing,  not  with  oil,  is 
passed  down  over  the  base  of  the  tongue  into  the  esophagus.  It  is 
practically  impossible  to  pass  it  into  the  larynx.  I  have  washed 
the  stomachs  of  many  hundred  children  and  the  introduction  of 
the  tube  has  never  been  attended  with  difficulty.  When  the  tube 
has  entered  the  esophagus,  it  should  be  passed  rapidly  into  the 
stomach.  At  least  nine  inches  of  the  tube  will  be  required  to 
reach  the  lower  portion  of  the  stomach.  At  first  the  child  will 
cough,  retch,  and  become  red  in  the  face,  but  this  need  cause  no 
alarm.  He  will  soon  cry  and  begin  to  breathe  regularly.  When 
the  tube  is  in  position,  the  funnel  should  be  held  the  length  of  the 
tube,  two  and  one-half  to  three  feet,  above  the  patient's  body,  and 
the  water,  which  should  first  be  boiled,  poured  into  it.  At  first  the 
water  may  remain  stationary  in  the  funnel,  owing  to  the  pressure 
of  air  in  the  stomach  and  the  straining  of  the  child.  When  the 
child  relaxes  or  the  air  escapes,  being  forced  upward  through  the 
water,  the  water  will  pass  rapidly  into  the  stomach. 

The  apparatus  described  under  Gavage  (page  136,  Fig.  17)  is 
used.  It  should  always  be  boiled  before  using.  If  much  mucus  is 
present,  a  i  percent  solution  of  boric  acid  or  borax  may  be  used. 
The    amount    introduced    into    the    stomach    at    one    time   varies 


LAVi^GE —  STOMACH- WASHING 


[8r 


with  the  age  of  the  child.  In  a  baby  of  one  week,  one  ounce 
may  be  used;  at  six  weeks,  two  ounces;  at  six  months,  from  four 
to  six  ounces.  It  is  rarely  advisable  to  introduce  more  than  six 
ounces  at  one  time.  The  fluid  is  allowed  to  run  into  the  stomach 
and  is  then  siphoned  out  by  lowering  the  funnel,  the  process  being 


Fig.  20. — Lavage. 


repeated  until  the  fluid  returns  perfectly  clear.     From  one  to  two 
pints  of  water  may  be  necessary  to  complete  the  washing. 

Indications. — It  is  rarely  necessary  to  wash  the  stomach  oftener 
than  twice  in  twenty-four  hours.  Ordinarily,  in  the  acute  vomit- 
ing cases,  one  washing  daily  for  four  or  five  days  will  answer.  In 
cases  of  chronic  indigestion  with  regurgitation,  the  washing  will  be 


l82  GASTRO-ENTERIC    DISEASES 

needed  less  frequently.  Here,  once  a  day,  or  once  every  second  or 
third  day,  will  answer. 

The  following  is  frequently  the  history  of  a  case  of  chronic  indiges- 
tion with  vomiting:  There  has  been  for  several  weeks,  vomiting  of 
food  and  mucus,  two  or  three  times  daily.  The  stomach  was  washed, 
the  child  carefully  dieted  with  a  plain  barley-water  or  a  weak  milk 
mixture,  and  no  vomiting  had  occurred  for  perhaps  twelve,  twenty- 
four,  thirty-six,  or  forty-eight  hours,  when  the  regurgitation  or 
vomiting  again  commenced  as  before.  In  such  a  case  it  will  soon 
be  learned  how  frequently  the  washings  should  be  repeated  in 
order  to  control  the  vomiting.  A  recent  patient  represents  my 
management:  A  child  six  months  old  suffering  from  malnutrition 
had  a  history  of  persistent  vomiting  after  each  feeding.  A  greater 
part  of  the  food  taken  was  lost.  What  was  not  vomited  was  digested 
imperfectly,  as  was  shown  by  the  stools.  The  stomach  was  washed 
and  a  large  quantity  of  thick  mucus  and  curds  removed.  The  child 
was  placed  on  a  barley-water  diet.  There  was  no  vomiting  for  three 
feedings  and  then  only  a  small  quantity  of  barley-water  was  thrown 
off.  After  three  days,  with  daily  washings,  the  vomiting  entirely 
subsided.  The  child  was  put  on  a  weak  milk  mixture,  one-fifth 
milk  and  four-fifths  barley-water,  and  no  vomiting  of  moment 
resulted.  The  food  was  carefully  strengthened,  and  although  in 
two  weeks  the  vomiting  had  entirely  ceased,  the  washings  were 
continued  at  intervals  of  two  or  three  days  for  a  month,  until  the 
water  siphoned  out  was  free  from  mucus.  In  severe  cases  of  chronic 
indigestion  the  washings  at  intervals  of  two  or  three  days  may  be 
continued  with  advantage  for  several  months. 

It  must  be  remembered  that  in  these  chronic  cases  of  indigestion, 
the  patient  is  ill  through  abuse  of  the  stomach — usually  because  too 
strong  food  has  been  given,  or  too  much  of  a  suitable  food  was 
given  at  too  frequent  intervals.  As  important,  then,  as  the  stom- 
ach-washing, is  the  placing  of  a  child  on  a  food  suited  to  its  diges- 
tive capacity.     Lavage  is  of  Uttle  service  if  the  bad  feeding  continues. 

The  field  of  usefulness  of  lavage  is  not  entirely  confined  to 
vomiting  cases.  Children  with  indifferent  appetite  and  limited 
food  capacity,  without  vomiting,  are  often  greatly  benefited  by 
it.  A  story  frequently  heard  in  our  consulting  room  is  as  follows : 
Food  is  taken  without  relish.  The  child  must  be  coaxed  to  eat. 
There  is  loss  of  appetite,  usually  the  result  of  improper  food  or 
faulty  feeding  methods.  Some  patients  are  absolutely  indifferent 
to  food;  many  refuse  it  altogether.  In  this  class  of  patients  a 
stomach-washing  once  a  day  will  often  be  followed  by  a  surprising 
improvement  in  the  appetite.  I  know  of  no  better  appetizer  for 
many  of  these  pitiful  looking  babes.  In  not  a  few  instances  I  have 
been  surprised  at  the  large  amount  of  mucus  removed  from  the  stom- 
ach of  one  of  these  children  in  whom  there   had   been   no  vomiting 


DILATATION    OF    THE    STOMACH  183 

whatever,  which  teaches  us  that  there  may  be,  in  infants,  stomach 
disorders  of  considerable  importance  without  vomiting  or,  in  fact, 
without  any  other  symptom  than  loss  of  appetite  and  malnutrition. 

HEMORRHAGE  FROM  THE  STOMACH;  VOMITING  OF  BLOOD 
Excluding  hematemesis  in  the  newly  born,  the  vomiting  of  blood 
by  infants  has  been  due,  in  my  experience,  to  ulceration  of  the 
stomach  (page  184),  to  purpura  fulminans  (Henoch's),  or  to  acciden- 
tal causes.  In  two  of  my  proved  cases,  extensive  ulceration  of  the 
stomach  was  found  at  autopsy.  A  boy  six  years  of  age  died  on  the 
third  day  with  purpura  fulminans.  There  were  profuse  hemorrhages 
from  the  stomach,  from  the  mucous  surfaces,  and  under  the  skin. 
Ulceration  of  the  stomach  is  usually  associated  with  marked  gastric 
disturbance,  such  as  is  seen  in  gastritis  and  in  the  different  forms  of 
malnutrition.  Accidental  sources  include  the  swallowing  of  blood, 
which  may  take  place  as  the  result  of  a  nasal  hemorrhage  or  from 
a  blow  or  fall  causing  injury  to  the  nose  or  mouth  or  from  the  presence 
of  a  foreign  body  in  one  of  the  nostrils.  Injury  to  the  pharynx 
also  may  be  followed  by  hemorrhage  sufficient  to  cause  vomiting, 
if  the  blood  is  swallowed.  A  case  of  hematemesis  in  a  well-nourished 
breast-fed  infant  five  months  of  age,  gave  me  a  great  deal  of  anxiety. 
The  vomiting  of  blood  continued  for  several  days  without  the 
slightest  evidence  as  to  its  source.  It  occurred  two  or  three  times 
a  day,  usually  shortly  after  nursing,  the  quantity  of  blood  being 
especially  large  after  the  early  morning  nursing.  There  were  no 
cracks  or  fissures  in  the  mother's  nipples,  nor  could  blood  be  made 
•to  exude  from  any  portion  of  the  nipples  on  reasonably  strong  pres- 
sure. I  concluded,  nevertheless,  that  its  source  must  be  the  breast, 
and  applied  a  breast-pump,  making  use  of  as  strong  suction  as 
possible,  and  obtained  milk  with  a  large  mixture  of  blood.  Evi- 
dently there  had  been  a  rupture  of  some  of  the  smaller  blood-vessels 
in  the  gland  behind  the  nipple.  At  the  first  nursing,  the  child  was 
very  hungr)^  and  tugged  vigorously  at  the  breast,  which  doubtless 
explains  why  the  early  morning  vomiting  showed  the  most  blood. 

DILATATION  OF  THE  STOMACH 

In  children  of  any  age  the  stomach  capacity  may  be  found 
greatly  increased.  Bottle-fed  infants  under  one  year  of  age  furnish 
the  most  of  the  cases. 

In  the  absence  of  pyloric  stenosis  (page  185),  the  persistent 
feeding  of  too  large  quantities  of  food  is  the  cause.  It  is  not  at 
all  infrequent,  in  cases  of  malnutrition  and  athrepsia,  to  find  the 
patients  taking  at  every  feeding  from  two  to  three  ounces  above 
the  normal  stomach  capacity  for  children  of  their  size  and  weight. 
Infants  with  dilated  stomachs  almost  invariably  suffer  from  in- 
digestion,   usually   with   the   vomiting   of   milk  curds   and   mucus. 


1 84  GASTRO-ENTERIC   DISEASES 

the  vomiting  generally  taking  place  a  considerable  time  after  the 
feeding. 

Oftentimes,  in  these  cases,  the  nourishment  that  has  been  given 
is  of  the  proper  strength,  and  all  that  will  be  required  is  to  reduce 
the  quantity  allowed  and  perhaps  increase  the  frequency  of  the 
feedings.  The  stomach  should  be  washed  daily,  if  the  child  resists 
the  simple  reduction  in  the  amount  of  fluid.  Particularly  is  the 
stomach  to  be  washed,  if  there  is  a  tendency  to  fermentation  in 
the  stomach-contents.  The  food  should  contain  a  low  fat  and  a 
moderate  amount  of  sugar.  A  reasonably  high  proteid  may  usually 
be  given.  Because  of  the  tendency  to  fermentation,  these  cases 
do  badly  on  the  gruel  diluents  also,  which,  if  they  have  formed  a  part 
of  the  child's  diet,  are  to  be  discontinued.  Small  doses  of  bismuth 
subnitrate — five  grains,  with  two  grains  bicarbonate  of  soda,  two 
hours  after  each  feeding — have  a  decidedly  beneficial  effect.  Hy- 
drochloric acid  should  not  be  given  and  pepsin  is  unnecessary. 

Dilatation  of  the  stomach,  after  the  eighteenth  month,  will  be 
found  due  to  the  same  cause  of  overfeeding,  or  the  condition  may 
have  been  brought  forward  from  earlier  infancy.  At  this  age,  it  is 
seen  most  frequently  in  children  who  take  large  quantities  of  milk 
with  their  regular  meals.  Milk  being  no  longer  a  necessary  part  of 
the  diet,  it  may  now  be  replaced  by  more  concentrated  food,  such  as 
meat,  eggs,  and  cereals  in  moderate  amount.  Not  over  four  ounces 
of  fluid  should  be  given  with  any  one  meal.  The  habit  of  drinking 
with  meals  is  best  broken  by  encouraging  the  child  to  drink  between 
meals.  One  hour  before  each  feeding  he  should  be  given  eight 
ounces  of  water.  It  should  be  given  cool,  not  cold,  at  a  tempera- 
ture of  from  50°  to  60°  F.,  and  should  be  drunk  slowly.  It  is  partic- 
ularly necessary  to  give  water  before  the  first  meal  of  the  day. 

ULCERATION  OF  THE  STOMACH 

In  a  large  autopsy  experience  among  infants  and  young  children, 
I  have  as  yet  to  see  a  perforating  ulcer,  either  tuberculous  or  other- 
wise. In  fact,  aside  from  those  of  the  newly  born  I  have  seen  at 
autopsy  only  two  cases  of  ulceration.  In  three  other  cases,  the 
diagnosis  of  ulceration  was  made  because  of  hematemesis.  In  one, 
a  child  one  month  old,  blood  was  repeatedly  vomited.  The  child 
bled  to  death.  At  autopsy  about  two  ounces  of  coagulated  blood 
were  found  in  the  stomach.  The  mucous  membrane  of  the  stomach 
was  the  seat  of  many  ulcers  varying  in  size,  but  none  exceeding 
one-sixteenth  of  an  inch  in  diameter.  Another  patient,  three  months 
old,  had  chronic  gastro-enteritis  with  occasional  vomiting  of  blood. 
The  child  died  from  exhaustion,  the  autopsy  showing  multiple  small 
ulcers  in  the  mucous  membrane  of  the  stomach.  That  ulcerations, 
even  of  a  mild  degree,  play  any  great  part  in  the  digestive  disorders 
of  infants  and  young  children  is  disproved  by  the  infrequency  of 


CONGENITAL    PYLORIC    STENOSIS  1 85 

the  lesion  at  autopsy,  in  children  dying  from  gastro-enteric  or 
other  diseases. 

In  treating  cases  of  gastric  disorders  by  stomach-washing,  it  is 
comparatively  rare  that  blood  is  found  in  the  water  siphoned  off. 
At  rare  intervals  the  water  may  be  tinged  with  blood,  but  the 
washings  invariably  should  be  continued  in  spite  of  this,  as  I  have 
never  known  any  hemorrhage  of  moment  to  follow.  The  blood 
which  appears  under  these  conditions  is  doubtless  from  the  capil- 
laries of  the  congested  mucous  surface,  distended  as  a  result  of  strain. 
Although  such  cases  are  rare,  one  never  knows  but  that  his  next 
case  will  be  one  of  them. 

Treatment. — In  the  event  of  persistent  vomiting  of  blood  of 
small  or  large  amount  which  cannot  otherwise  be  accounted  for,  it 
should  be  regarded  as  coming  from  the  walls  of  the  stomach.  Under 
these  conditions,  food  by  means  of  the  stomach  should  be  discon- 
tinued and  the  nutrient  enema  (page  139)  should  be  brought  into  use. 
Bromid  and  chloral,  or  stimulants  if  necessary,  may  thus  be  given 
with  the  food.  Suprarenal  extract  in  one-grain  doses  should  be 
given  hourly  and  continued  for  twelve  hours  after  the  vomiting 
ceases.  After  thirty-six  hours  water  may  be  given  in  small  amounts, 
and  the  giving  of  the  usual  milk  mixture  diluted  one-half,  in  small 
quantities,  two  or  three  ounces,  may  also  be  commenced.  The 
normal  diet  should  not  be  resumed  in  less  than  a  week,  even  with 
an  entire  absence  of  vomiting  during  this  period. 

CONGENITAL  PYLORIC  STENOSIS 

In  the  chapter  on  persistent  vomiting  it  will  be  found  that 
stenosis  of  the  pylorus  is  mentioned  as  one  of  the  possible  causative 
factors  of  repeated  vomiting.  The  condition  of  hypertrophy  of 
the  pyloric  end  of  the  stomach  with  narrowing  of  the  outlet  is 
practically  always  of  congenital  origin,  even  though  the  symptoms  of 
vomiting  may  not  appear  for  three  or  four  weeks  after  birth. 

That  a  stenosis  exists,  is  suggested  by  the  character  of  the 
vomiting.  Two  factors  are  at  work  in  these  cases,  the  spasm  and 
the  stenosis.  The  time  of  the  occurrence  of  the  vomiting  suggests 
also  the  seat  of  the  trouble.  Three  or  four  nursings  or  feedings  may 
be  taken  and  retained,  when  suddenly  a  considerable  portion  of  these 
feedings  is  ejected.  The  vomiting  differs  from  that  of  gastric  disor- 
der, in  that  it  is  expulsive,  one  forcible  ejection  taking  place  which 
removes  all  or  a  portion  of  the  stomach  contents.  There  usually  is  no 
associated  diarrhea  or  other  evidence  of  intestinal  involvement,  aside 
from  constipation,  this  being  in  marked  contrast  with  the  ordinary 
acute  digestive  derangements  of  infancy.  In  two  hours  after  feeding, 
the  stomach  of  a  nursing  infant  should  be  practically  empty.  The 
introduction  of  a  stomach-tube  in  a  case  of  stenosis  will  show  that  a 
greater  part  or  all  of  the  food  is  still  in  the  stomach  if  it  has  not 


1 86  GASTRO-ENTERIC    DISEASES 

previously  been  vomited.  The  "stomach  wave"  is  one  of  the 
characteristic  signs  of  the  condition.  Beginning  at  the  cardiac  end, 
the  contractions  of  the  stomach  produce  a  wave-Uke  movement  of 
the  abdominal  wall,  as  though  a  ball  were  moving  under  it,  making  a 
pressure  on  the  parietes.  The  ball-like  movement  is  further  sug- 
gested by  the  gradual  relaxation  of  the  portion  of  the  abdominal 
wall  first  contracted,  which  leaves  the  parietes  as  before.  The 
contraction  continues  until  the  pylorus  is  reached.  Persistent  vom- 
iting, expulsive  in  character,  in  a  newly  born  infant,  associated 
with  scanty,  well-digested  stools,  should  always  suggest  to  our  mind 
the  possibility  of  pyloric  stenosis. 

Treatment. — The  only  treatment,  in  the  great  majority  of  in- 
stances, is  operation.  In  a  gastro-enterostomy,  considering  the 
age  of  the  patient  and  the  usual  emaciated  condition,  the  out- 
look is  not  promising,  the  mortality  being  necessarily  high.  A 
few  cases  in  which  there  is  but  little  hypertrophy  and  moderate 
stenosis  recover  without  operation.  Before  resorting  to  operation, 
there  must  be  the  strongest  evidence  that  the  child  will  not  recover 
without  it,  as  operation  should  be  a  last  resort.  This  should  be  de- 
cided as  early  as  possible,  before  there  is  a  loss  of  too  much  strength 
and  power  of  resistance.  By  weighing  the  stripped  patient  daily,  it 
is  not  difficult  satisfactorily  to  convince  ourselves  of  the  advisability 
of  delay.  If  the  child  loses  weight  day  after  day,  operation  by  gastro- 
enterostomy or  divulsion^  should  not  be  delayed.  If  the  weight 
is  stationary,  or  if  but  a  slight  gain  is  made,  temporizing  may  be 
permitted,  with  the  hope  that  greater  improvement  will  follow. 
The  patient  should  be  given  the  advantage  of  the  best  nourishment 
possible — human  milk.  If  the  mother  cannot  nurse  the  patient,  a 
wet-nurse  should  be  secured.  The  stomach  should  be  washed  at 
least  once  daily  to  remove  the  food  residue. 

PREVENTION  OF  THE  ACUTE  INTESTINAL  DISEASES 
OF  SUMMER 

Preventive  medicine,  so  called,  is  at  the  present  time  engaging 
the  attention  of  the  best  medical  minds.  The  acute  intestinal 
diseases  of  summer,  with  their  large  infant  mortality,  offer  a  better 
field  for  life-saving  measures  than  does  any  other  department  of 
pediatrics. 

Potent  etiologic  factors  in  summer  diarrhea  are  unfavorable 
chmate  and  unfavorable  environment.  In  the  class  which  furnishes 
the  largest  mortality,  climate  cannot  be  changed  for  a  sufficient  num- 
ber to  exert  any  great  influence  on  the  general  mortality.  Through 
education  the  environment  may  be  radically  improved,  but  it  can- 
not be  changed.     The  hot  months  come  and  the  tenement  child  must 

^  Dr.  Geo.  F.  Still,  of  London,  who  has  had  considerable  experience  with 
different  operative  methods,  advises  divulsion. 


PREVENTION  OF  ACUTE  INTESTINAE  DISEASES  OF  SUMMER        187 

remain  at  home.  Excursions  and  outings  of  various  kinds  are  valu- 
able in  a  small  way  to  comparatively  few,  as  the  child  must  return 
to  the  tenement  home  at  night  or  after  a  few  days'  absence,  so  that 
in  our  consideration  of  this  class  of  patients  in  large  cities  we  must 
accept  unfavorable  environment  and  hot  weather — in  other  words, 
we  must  treat  these  cases  in  their  homes.  Those  more  fortunately 
situated,  who  can  have  the  advantage  of  the  country  and  intelligent 
care,  are  proportionately  less  liable  to  diarrheal  diseases.  Other 
than  cHmate  and  environment,  the  determining  etiologic  factors 
among  all  classes  are:  first,  a  disordered  gastro-enteric  tract; 
second,  infected  food;  third,  faulty  feeding  methods;  fourth,  an 
absence  of  appreciation  on  the  part  of  the  parents  and  physicians 
of  the  fact  that  an  attack  of  diarrhea  or  vomiting,  or  even  a  green 
undigested  stool,  occurring  in  an  infant  under  eighteen  months  of 
age  during  the  hot  weather,  is  to  be  looked  upon  as  a  serious  matter 
requiring  prompt  attention. 

Children  as  well  as  adults  are  frequently  exposed  to  disease  from 
different  sources,  of  which  they  are  ignorant,  because  their  power  of 
resistance  is  sufficient  for  their  protection.  With  milk,  the  most 
readily  infected  of  all  nutritional  substances,  as  the  chief  article  of 
diet,  it  may  safely  be  assumed  that  few  infants  pass  through  the 
heated  term  without  having  been  subjected  repeatedly  to  infection 
from  bacteria  sufficient  to  produce  grave  illness.  An  infant's  best 
safeguard  against  intestinal  infection  is  a  strongly  resistant  gut, 
which  is  best  secured  by  the  absence  of  digestive  disturbances  at  all 
seasons  of  the  year.  The  summer  mortality  from  intestinal  disease 
has,  thus,  a  decided  bearing  upon  the  feeding,  and  intelligent  man- 
agement generally,  throughout  the  year. 

Seventeen  years  ago,  at  the  commencement  of  my  junior  service 
on  the  house  staff  at  the  Country  Branch  of  the  New  York  Infant 
Asylum,  I  gained  my  first  knowledge  of  summer  diarrhea.  While 
making  rounds  early  one  morning  in  June,  the  matter  of  summer 
mortality  among  the  infant  population  was  being  discussed  with  the 
resident  physician,  the  late  Dr.  Clarence  E.  Kimball.  I  asked  whv 
they  had  such  a  large  summer  mortality  in  an  institution  situated,  as 
it  was,  at  a  considerable  elevation,  in  the  open  country,  constructed 
on  the  cottage  and  dormitory  plan,  with  the  additional  advantage 
of  good  milk,  favorable  environment,  good  nursing,  and  competent 
medical  attendance.  His  reply  was:  "Take  your  pencil  and  write 
as  we  go  through  the  wards  the  names  of  the  children  I  indicate." 
I  did  so,  and,  at  the  completion  of  the  round,  he  directed  me  to 
keep  the  list  of  thirty  names,  saying  that  these  children  probablv 
would  not  survive  the  summer.  Seeking  an  explanation  I  remarked 
that  they  were  not  delicate  or  athreptic.  "No,"  he  replied,  "they 
look  well,  but  they  have  foolish,  ignorant  mothers,  and  susceptible 
intestines.     They  have  had  frequent  attacks  of  diarrhea  and  indiges- 


1 88  G ASTRO- ENTERIC   DISEASES 

tion  during  the  winter  and  spring.  The  mothers  steal  food  from 
their  own  table  and  give  it  to  the  children  when  the  orderlies  and 
nurses  are  out  of  the  wards.  These  children  have  but  little  intestinal 
resistance,  and  will  give  us  our  first  fatal  diarrheal  cases  when  the 
hot  weather  comes."  I  kept  my  list  and  found  that  the  accuracy  of 
his  prediction  was  startling.  But  four  of  the  children  named  sur- 
vived the  summer. 

Since  that  time  I  have  had  abundant  opportunity  to  observe 
that  the  children  who  have  had  frequent  attacks  of  intestinal  indiges- 
tion during  the  colder  months  furnish  our  severe  cases  during  the 
summer.  A  most  important  feature,  then,  in  prophylaxis  is  to 
teach  the  mother  how  to  feed  and  care  for  the  child  all  the  year  round, 
and  thus,  by  keeping  well,  he  maintains  a  high  grade  of  intestinal 
resistance. 

Etiology. — The  principal  immediate  etiologic  factor  of  the  dis- 
ease which  we  have  under  consideration  is  an  infection  of  the  gastro- 
enteric contents  by  bacteria.  The  infecting  elements  are  usually 
introduced  by  means  of  contaminated  food  and  unclean  feeding 
apparatus. 

New  York  City  Conditions  and  How  to  Correct  Them. — For  the 
well-to-do,  we  have  high-priced  dairies  whose  product  sells  at  from 
fifteen  to  eighteen  cents  a  quart.  For  others,  we  have  what  is 
known  as  "certified  milk,"  produced  under  the  supervision  of  a 
committee  of  medical  men,  which  retails  at  twelve  cents  a  quart. 
Obviously,  the  majority  of  our  infant  population  are  not  fed  on  these 
milks.  The  Straus  Laboratories,  which  supply  safe  sterilized  milk 
in  New  York  city,  are  able  to  furnish  it  to  but  a  small  proportion  of 
the  tenement  population.  The  other  milks,  the  so-called  "market 
milks,"  supply  nutrition  for  an  immense  majority  of  the  infants  of  the 
poorer  classes.  These  milks  have  been  greatly  improved  of  late 
through  the  efforts  of  the  medical  profession  and  the  New  York 
Health  Department;  but  the  matter  of  the  regulation  of  milk  pro- 
duction and  sale  is  a  large  one,  and  the  powers  of  the  authorities  are 
limited.  The  majority  of  our  infant  population,  then,  are  fed  on 
milk  which,  for  them,  is  not  a  safe  food ;  and  it  is  among  these  infants 
that  the  large  mortality  occurs,  and  will  continue  in  spite  of  seashore 
visits,  daily  excursions,  and  the  efforts  of  the  summer  corps  of 
Health  Department  physicians.  It  will  continue  until  every  large 
municipality,  such  as  New  York  city,  shall  establish  milk  depots  and 
ice  stations  where  safe  milk,  and  ice  to  keep  it  safe,  may  be  obtained 
at  a  nominal  cost,  or  free,  if  the  parents  are  not  able  to  pay  for 
it.  A  visiting  physician  for  these  people  is  not  absolutely  necessary, 
nor  is  a  visiting  trained  nurse, — both  are  expensive  luxuries;  but 
what  is  necessary  is  the  appointment  for  a  given  district  of  women 
with  just  plain  common  sense  to  teach  the  uninformed  mothers, 
who  are  doing  their   best   according  to   the   light  they  have,  the 


PREVENTION  OF  ACUTE  INTESTINAL  DISEASES  OF  SUMMER        1 89 

simple  details  of  the  infant's  care,  easily  carried  out  when  they  know 
how,  but  so  rarely  done  because  they  do  not  know  how. 

Dispensary  Rules  of  Universal  Application. — At  the  out-patient 
department  of  the  Babies'  Hospital  and  the  New  York  Polyclinic, 
I  have  had  abundant  opportunity  to  come  into  close  contact  with 
a  great  many  tenement  mothers  and  tenement  children.  At  these 
institutions  we  have  a  clientele  fairly  regular  in  attendance,  year 
after  year;  for  as  one  baby  after  another  appears  in  the  family, 
they  are  brought  to  us  for  treatment.  At  these  dispensaries  we 
have  a  surprisingly  low  summer  diarrhea  mortality,  because  we 
teach  the  mothers  how  to  feed  and  care  for  their  children  all  the 
year  round.  They  are  taught  the  value  of  fresh  air,  the  use  of 
boiled  water  as  a  beverage,  and  the  benefits  of  frequent  spongings 
on  hot  days.  Both  private  and  dispensary  mothers  whose  children 
are  under  my  care  are  given  pamphlets  of  instruction  and  also  oral 
teaching  bearing  on  these  points,  and  particularly  as  to  the  care 
of  the  feeding-bottle  and  the  milk.  In  case  special  articles  of  diet 
are  to  be  given,  they  are  taught  how  to  prepare  them.  Written 
directions  are  always  given  covering  the  point ;  nothing  is  left  to  the 
memory.  Each  mother  and  nurse  has  it  impressed  upon  her  that  she 
must  wash  her  hands  in  soap  and  water  before  touching  the  baby's 
food  or  feeding  apparatus  for  any  purpose,  and  that  there  must  be 
a  covered  vessel  in  which  the  soiled  napkins  are  to  be  kept  until 
w^ashed.  At  the  first  sign  of  intestinal  derangement,  regardless  of 
the  season  of  the  year,  they  are  taught  to  stop  the  milk  at  once,  to 
give  instead  a  cereal  water,  such  as  barley-water  or  rice-water,  and 
a  dose  of  castor  oil.  It  is  impressed  upon  them  that,  in  winter  as 
well  as  summer,  a  green,  watery  stool  means  that  the  baby  is  ill 
and  needs  treatment.  When  the  mother  learns  the  above  lesson  for 
December,  January,  and  March,  she  will  not  forget  it  in  July. 
Furthermore,  as  a  result  of  the  immediate  correction  of  a  child's  di- 
gestive disorder  during  the  winter  months,  we  have  a  much  less 
fertile  field  for  pathogenic  bacteria  during  the  summer. 

Prompt  Treatment  Essential. — Comparatively  few  cases  of  in- 
testinal diseases  have  pronounced  toxic  symptoms  at  the  outset. 
At  first  there  are  evidences  of  a  mild  infection  only.  There  may 
be  vomiting,  with  several  green,  watery  stools,  with  a  slight  ele- 
vation of  temperature,  or  the  symptoms  may  be  still  more  mild 
— only  one  or  two  loose,  green  defecations.  Prompt  treatment 
at  this  time,'  even  in  a  crowded  tenement,  usually  means  prompt 
recovery.  When  treatment  is  delayed,  when  the  administration  of 
milk  is  continued,  severe  toxic  symptoms  and  intestinal  lesions  are 
almost  invariably  the  result. 

New  York  City  Experiments. ^An  interesting  demonstration  of 
what  may  be  accomplished  by  proper  care  was  made  under  the  direc- 
tion of  Dr.  WilHam  H.  Park,  of  the  New  York  Health  Department, 


I90  GASTRO-ENTERIC    DISEASES 

during  the  summer  of  1902.  Fifty  tenement  children,  ranging  from 
three  to  nine  months  of  age,  were  selected  for  the  experiment.  These 
children  were  all  fed  on  the  Straus  milk.  They  were  visited  two  or 
three  times  a  week  by  physicians  especially  assigned  to  them.  The 
mothers  were  carefully  instructed  as  to  the  care  of  the  milk,  the  feed- 
ing apparatus,  and  in  other  necessary  details.  With  the  first  signs  of 
illness,  the  milk  was  to  be  stopped,  the  physician  notified,  and  suit- 
able treatment  instituted.  Among  these  fifty  tenement  children,  all 
under  one  year  of  age,  all  bottle-fed,  selected  at  random,  there  was 
not  one  death  during  the  summer.  This  valuable  observation  bears 
out  my  contention  that  the  deaths  of  summer  diarrhea  among 
tenement  children  may  be  greatly  reduced  by  the  use  of  good  milk 
given  under  proper  supervision,  supplemented  by  prompt  and  compe- 
tent medical  care  at  the  first  sign  of  illness.  Perhaps  in  i  percent 
of  the  cases  of  summer  diarrhea  a  very  severe  direct  infection  is 
evident,  and  the  condition  of  the  patient  very  grave  from  the  onset. 
In  the  remainder  the  invasion  is  gradual;  and,  if  the  warnings  are 
heeded,  the  illness  will  usually  terminate  quickly  in  recovery. 

How  to  Secure  Good  Milk. — To  those  of  my  patients  of  the  bet- 
ter class  who  go  to  the  country  for  the  summer,  and  who  have 
cows  of  their  own  in  order  to  control  their  milk-supply,  I  give  the 
following  directions:  Before  milking,  the  udders  and  belly  of  the 
cow  should  be  wiped  with  a  damp  cloth  to  remove  clinging  par- 
ticles of  dirt.  It  is  in  these  droppings  containing  manure  that 
the  most  dangerous  forms  of  bacteria  of  decomposition  enter  the 
milk.  The  milker  should  wash  his  hands  before  milking.  The 
first  few  jets  of  milk,  coming  from  the  ducts  near  the  openings,  are 
apt  to  be  swarming  with  bacteria,  and  are  therefore  discarded. 
Immediately  after  the  milking,  the  milk  should  be  strained  through 
several  thicknesses  of  cheese-cloth,  or  through  absorbent  cotton, 
into  an  ordinary  milk  bottle,  which  is  at  once  placed  in  a  pail 
of  cracked  ice.  Such  simple  care  as  this,  even  on  an  ordinary  farm, 
gives  a  very  low  bacteria  count.  As  may  readily  be  seen,  it  is 
attended  with  very  little  trouble  and  expense.  Different  dairies 
throughout  the  country,  which  are  located  near  my  patients  for  the 
summer,  meet  the  above  requirements,  for  which  they  receive  an 
extra  compensation  of  five  or  six  cents  a  quart. 

The  Necessity  for  Education. — It  will  be  seen  from  the  foregoing 
that  the  suggestions  we  have  offered  are  all  included  under  the  one 
general  heading  of  Education.  The  mother  must  be  educated  how 
to  live,  how  to  care  for  the  baby,  how  to  clothe  him  and  bathe  him 
during  the  summer.  It  must  be  impressed  upon  her  that  he  needs  all 
the  fresh  air  available.  She  must  be  educated  to  the  point  of  know- 
ing what  to  do  at  the  first  sign  of  threatened  disease.  Municipalities 
must  be  educated  to  appreciate  their  responsibility  as  factors,  nega- 
tive or   positive,  in  the  summer  mortality.     The  farmer  must  be 


ACUTE   GASTRO-ENTERIC   INFECTION  I91 

educated  as  to  how  to  produce  safe  milk,  and  the  consumer  must  be 
educated  to  appreciate  its  value  and  pay  for  it.  Above  all  others, 
the  physician  must  be  educated  along  these  lines  so  as  to  be  able 
to  teach  the  mothers  how  to  do  the  right  thing  as  to  the  care  of 
her  children  all  the  year  round. 

ACUTE  GASTRO-ENTERIC  INFECTION;    CHOLERA   INFANTUM; 
GASTRO-ENTERIC  INTOXICATION 

This  form  of  infection,  while  acute  in  character,  is  rarely  of 
primary  origin.  It  is  usually  preceded  by  a  disordered  gastro-enteric 
digestion.  The  onset  of  the  urgent  symptoms,  however,  is  usually 
most  pronounced,  the  child  being  taken  suddenly  with  persistent 
vomiting,  retching,  and  the  passing  of  large  watery  stools,  usually 
greenish  in  color.  The  prostration  is  extreme,  the  respiration  be- 
comes shallow,  the  eyes  sunken,  the  skin  ashen  in  color,  the  pulse 
soft  and  very  rapid.  The  temperature  may  be  high — 105°  F.  or 
106°  F. — or  it  may  never  rise  above  the  normal.  The  low-tempera- 
ture cases  with  symptoms  of  pronounced  prostration  give  us  our 
most  hopeless  cases.  The  system  is  so  overwhelmed  by  the  in- 
fection that  the  patient  is  unalale  to  react,  I  have  seen  infants  die 
in  twelve  hours  after  the  onset  of  the  active  symptoms.  From  this 
extreme  degree  of  infection  cases  vary  in  severity,  to  one  who  is 
taken  with  a  sharp  attack  of  vomiting  and  high  fever.  Occurring 
coincident  with  or  following  within  a  few  hours,  there  are  several 
large  watery  stools.  The  fever  soon  subsides.  The  stomach  is 
washed,  the  milk  is  withheld,  boiled  water  or  weak  barley-water  or 
rice-water  No.  i  (see  formulary)  is  given,  and  the  child  is  well  in  a 
day  or  two. 

Treatment. — The  management  of  the  case  depends  entirely  upon 
the  nature  and  urgency  of  the  symptoms.  In  the  acute  choleraic 
cases  with  repeated  vomiting,  severe  toxemia,  retching,  and  profuse 
watery  stools,  stomach-washing  and  bowel  irrigations  are  useless 
procedures.  What  we  must  do  is  to  support  the  patient  and  aid 
him  to  bear  the  poison  he  has  to  contend  with.  If  the  temperature 
is  high  with  a  dry,  hot  skin,  a  cool  pack  to  the  trunk,  85°  to  90°  F., 
which  is  moistened  with  water  at  this  temperature  every  half  hour, 
will  often  control  the  pyrexia.  If  the  feet  are  cold,  hot-water  bottles 
should  be  brought  into  use.  If  the  temperature  is  below  normal, 
and  the  peripheral  circulation  poor,  as  indicated  by  a  leaden  hue  of 
the  skin,  a  hot-water  bath  at  108°  F.  for  five  minutes  will  always 
be  of  service.  The  bath  may  be  repeated  at  half-hour  intervals. 
Other  than  this,  the  immediate  treatment  calls  for  hypodermic 
stimulation  and  sedatives.  The  administration  by  n:outh  of  food  or 
stimulants  should  not  be  attempted.  Tincture  of  strophanthus  and 
brandy,  hypodermatically,  have  answered  me  well  in  these  cases. 
Twenty  drops  of  brandy  with  one  drop  of  the  tincture  of  strophanthus 


K;.'  C.ASTKo  I'NI'l'MvMi'    KISIvASIvS 

ui;i\'  l»f  j;'^ '"  •''  iiitti  \  Ills  olOiic,  I  wo,  1  liicc,  oi  loiii  lioiiis,  (l(|Htl<lili^ 
upon  llic  iii).;iiu'\  (tl  tile  i';isc.  A  ctiiiihiii;!!  ion  ol  iiioipliiii  jiiul 
;ilii>|>iii  iii;i\  l)i-  iisid  in  tiiscs  willi  pii  sisUiit  \  ouiil  in;;,  willi  ;i  vii-w 
((>  colli  lolling  llic-  iiltcinpis  :il  voniiliii^  vvliidi  i-xluiusl  Uk-  patiriit, 
Hill  :ilst)  lo  (liniinisli  tlir  lonl  ilMUMls  loss  of  llic  lliiids  of  (lir  Ixxly, 
lioiii  llic  icp(,ili(i  l;ii);i'  watiTv  slools.  ()l»\ioiisl\  nioipliin  should 
not  l)c  i',i\cn  iiiiNs'.  Iliis  condilion  exists.  I'Oi  a  child  one  \cai"  of 
"K*'  r,\\  )'.'■''"  "'  nioiphin  is  v;i\c!i  with  ', ,,  i;!ain  atiopiii,  icpcalcd  as 
l-c(Hlircd,  nut  ollciici  than  once  in  two  lioiiis.  Altii  the  liist  \vav 
,,',)  ^laiii  ol  iiioiphiii  ina\  he  i;i\(ii  ;is  ;iii  inilial  dose.  lUnelicMal 
efh'cts  fioin  the  inoiphiii  will  1><'  luilcd  in  a  diniinntion  holh  of  the 
iiiiiiiliei  ol  stools  and  ol  the  \  «iniit  iiiv;.  In  niildi  i  casis  of  infcc-tioii, 
III  which  I  he  \oniilin.i;  and  llic  stools  arc  less  frc(|ncnt,  a  dilTiiiait 
conise  is  to  he  pinsiicd.  Ill  these  c;iscn  till  le  should  hi"  ail  ahst  iiK'iR-e 
fioni  food,  hoiled  walei  li(ini',  <;i\tii  if  I  he  child  i-aii  retain  it.  If 
\'oinilinj;  piisists,  the  walei  should  he  discontinued.  The  stomach 
should  1k'  washed  at  least  once  dail\  and  the  colon  inij^aled.  If 
the  iiii!;alion  l)iini;s  ;iwa\  nincns  and  fecal  niatlei,  it  shoidd  he 
icpcalcd,  at  iiitei\als  of  fioiii  cii^lit  to  IwcKc  lu.nis.  The  child 
shonld  iH\ei  lie  disliiilied  foi  this  piiipose  if  the  iiilestilic  coil 
limii'S  to  ciilpiN  itsell  .it  licciiieill  illtcixals.  A  lediictioll  ill  t  he 
tcinpcial  lite,  a  ccss.it  loll  of  the  \  omit  iiiv;,  and  a  diminntioii  of  the 
lilimhci  and  iiiipio\ement  in  the  ihaiactti  of  tlu'  slools  tell  lis 
whetlui  Ol  ii.it  the  CISC  is  doiu^  wi'll  and  (k-lcnuiiu'  llic  fiiillicr 
t  le.il  nieiit ,  afl(  1  I  he  iiiit  i.il  dosi-  of  oastoi"  oil  oioaloiiu'l  has  hciii  ^i\cti. 

.\s  ;i  iiile,  the  iillldi  I  I  \  pe  of  casi'  does  liittil  wluil  calomel  is  llScd. 
if  lli(  ic  is  a  t(  iidcncN  to  \..iiiit,  the  oil  will  laicK  \n-  ulaiiuil,  iinard- 
K'SS  of  how  it  is  >;ivcli.  I'loiii  ,'-  to  Z,,  i;iaiii  of  imIoiiuI  ni.i\  ])c  i;i\cii 
at  liftecii  MiiiMitc  intei\als  uiilil  one  i;iaiii  is  i;i\eii.  While  slower 
in  its  action,  it  is  iilliiiiatcl\  of  moie  hciulil  than  the  oil  which  is 
ii'icctcd.  Ihiiiii!.;  the  past  sninnui  1  lia\e  used  a  solution  of  sill 
phati- t)f  sodi  ((dauhci's  sail),  as  aiKocaled  h\  Mi.  I,.  I'.  I, a  I'clra, 
of  Niw  NOiU,  with  SMrprisin^l\  i;ood  usiilts.  ll  is  will  ntaiiicd. 
exeii  ill  llic  Ndiiiiliiii;  cases,  and  when  v;i\cii  in  doses  of  two  drams 
it  piodiices  ,1  lice  wateiA  cNacualioii  without  tencsmns.  1  nsiialU 
picsci  ihc  it  as  follows  : 

l{.      Sn.lnsiili.iial.s Sj 

Idixiiis  siiiipliois ^j 

.■Vijim' (|.  s,  11(1  \\v 

M.  ft,  suluiii. 

,Si^.        Two    ItMSpuoululs    l'\lM\     lIllllV    lilillllU'S   lllllil   llMIl    lIuSl'S  Ii.ivi- 

hirii  l.iki'u 

When  the  Nomiliiii,;  has  siihsidcd,  teaspooiifnl  doses  of  |)lain  water 
or  haiU'N'  w.ilci,  ;;>•""""  \\atei,  or  rice  water  should  he  usi-d  al 
fiflctMi  uiiniitc  Ol  h.df  honi  iiiici  \  als,  and  holh  incri'ascd  as  to  intcrx'al 
and  (iiiantitN  .is  the  c.ise  inipioxcs.      .Mcoliol  in  the  form  of   hraiidv, 


ACUTE    GASTRO-ICNTERIC    INFECTION  I93 

a  popular  treatment,  should  seldom  be  used  in  these  cases,  and  al- 
ways well  diluted,  usually  in  the  food.  Vomiting  babies  should  be 
given  brandy  very  sparingly  or  not  at  all,  as  it  is  apt  to  increase 
the  irritability  of  the  stomach. 

Milk  Substitutes. — It  is  well  in  using  milk  substitutes,  such  as 
cereal  waters,  to  use  alternately,  for  the  sake  of  variety,  three  or 
four  different  preparations.  The  child  will  not  so  soon  tire  of  the 
milk  substitute  as  when  but  one  is  given  and  more  food  will  be 
taken.  It  is  extremely  rare  that  the  substitutes  barley,  rice,  or 
granum  will  not  be  taken  if  used  in  this  way,  particularly  if  made 
more  palatable  by  the  addition  of  salt  and  sugar. 

The  termination  of  acute  intestinal  infection  is  in  death,  prompt 
recovery,  or  in  the  development  of  ileocolitis.  The  transition  to  an 
ileocolitis  in  some  cases  is  so  sudden  that  its  existence  from  the  onset 
is  often  assumed.  That  such  is  not  the  case  is  proved  by  a  large 
autopsy  experience  in  hospital  and  institution  work,  on  cases  dying 
in  a  day  or  two  from  toxemia  in  which  no  intestinal  lesions  of  conse- 
quence are  found.  When  the  diarrhea  with  loose  green  mucous 
stools  continues  with  fever,  it  means  that  an  ileocolitis  has  developed 
as  a  result  of  the  action  of  the  bacteria  and  the  absorption  of  toxins 
by  the  intestinal  mucous  membrane. 

Drugs. — Unusual  care  must  be  exercised  in  the  use  of  astringent 
drugs  in  the  cases  we  are  discussing.  I  refer  particularly  to  cases  that 
are  mild  or  moderately  severe.  It  is  to  be  remembered  that  it  is  in 
the  intestinal  contents  that  the  trouble  exists,  and  not  in  the  intesti- 
nal structure,  and  that  the  diarrhea  is  a  conservative  attempt  on  the 
part  of  Nature  to  protect  the  intestinal  structure.  Our  first  efforts 
therefore  should  not  be  directed  toward  stopping  the  diarrhea,  but  to- 
ward assisting  in  the  ehmination  of  the  intestinal  contents — the 
source  of  the  illness.  The  indiscriminate  use  of  opium  and  astringents 
may  do  irreparable  damage  in  a  very  short  time  through  a  locking 
up  of  the  intestine  with  its  bacteria  and  their  toxins,  which  may  be 
followed  by  a  sudden  rise  in  temperature,  convulsions,  coma,  and 
death.  Opium  is  a  most  useful  drug  in  diarrhea  in  children, 
but  it  must  be  used  with  caution.  When  there  is  tenesmus 
with  frequent  large  watery  stools,  it  may  be  given  in  small  doses 
sufficient  to  control  the  number  and  character  of  the  stools  with 
a  view  to  preventing  an  excessive  loss  of  fluids  from  the  body. 
It  should  never  be  given  when  there  are  only  four  or  five  free 
evacuations  in  twenty-four  hours,  as  in  these  cases  this  number 
is  required  to  maintain  proper  drainage.  The  opium  should  further 
be  given  independently  of  other  medication  so  that  its  use  may  be 
stopped  when  the  excessive  number  of  stools  ceases  or  in  the  event 
of  a  rise  in  temperature  after  it  has  been  given.  It  would  not  be 
desirable,  perhaps,  to  discontinue  the  bismuth  or  other  drugs 
which  may  have  formed  a  part  of  the  prescription.  In  using 
13 


194  GASTRO-ENTERIC   DISEASES 

Opium  I  prefer  the  Dover's  powder,  i  to  ^  grain  at  intervals  of 
two  or  three  hours,  for  a  child  from  six  to  eighteen  months  of  age. 
Bismuth  subnitrate  in  not  less  than  ten-grain  doses  at  two-hour 
intervals  has  given  most  satisfactory  results.  In  order  to  be  of 
service  it  must  produce  black  stools.  In  other  words,  if  the  bismuth 
is  not  converted  into  the  sulphid  in  the  intestine  it  apparently  is  of 
no  service;  if  it  passes  through  the  bowel  unchanged,  no  favorable 
influence  will  be  exerted  on  the  intestinal  contents.  This  occurs 
in  a  small  percentage  of  cases.  In  such  an  event  the  necessary 
amount  of  sulphur  is  supplied  by  the  use  of  the  precipitated  sul- 
phur, one  grain  being  added  to  each  dose  of  the  bismuth.  A 
convenient  and  agreeable  way  of  giving  the  bismuth  is  the  following : 

I^.     Bismuthi  subnitratis ov 

Syrupi  rhei  aromatici 5iij 

Aquae q.  s.  ad   5  iv 

M.     Sig. — One  teaspoonful  every  two  hours. 

If  sulphur  is  necessary  a  one-grain  powder  may  be  added  to  each  dose 
of  the  bismuth  mixture  at  the  time  of  its  administration.  In  the 
same  way  Dover's  powder,  if  opium  is  indicated,  may  be  dropped  into 
the  bismuth  mixture.  The  bismuth  is  continued  in  the  large  doses 
until  the  child  is  ready  for  milk,  when  the  dose  is  diminished  one-half 
and  continued  until  full  milk-feeding  is  permissible  or  until  con- 
stipation demands  its  discontinuance.  In  using  the  bismuth  in  the 
large  doses  advised,  it  is  necessary  that  the  chemically  pure  drug 
be  obtained.  If  free  nitric  acid  or  arsenic  is  present,  as  is  the  case 
in  some  of  the  commercial  bismuth  on  the  market,  vomiting  may 
result  or  symptoms  of  arsenical  poisoning  may  develop.  Irrigation 
of  the  colon  (page  207)  may  be  used  when  there  is  a  tendency  to 
bowel  inactivity  with  high  temperature.  With  loose  watery  passages 
it  is  not  called  for. 

Diet. — A  difficult  problem  of  no  little  importance  is  the  nutri- 
tion of  the  patient  after  the  acute  symptoms  have  subsided. 
When  the  temperature  has  been  normal  for  two  or  three  days,  when 
the  character  of  the  stools  improves  to  such  a  degree  that  freer 
feeding  is  to  be  thought  of,  unusual  care  is  necessary  in  order  to 
avoid  a  reinfection. 

Skimmed  Milk. — It  must,  of  course,  be  our  effort  to  resume 
milk-feeding  as  early  as  possible,  but  in  resuming  milk  the  amounts 
given  must  be  increased  very  gradually,  giving  at  first  only  from  one- 
quarter  to  one-half  ounce  of  skimmed  milk  in  every  second  feeding 
of  the  cereal  gruel.  In  not  a  few  cases,  even  these  small  amounts 
will  result  in  a  rise  of  temperature  and  a  return  of  the  diarrhea. 
There  are  always  bacteria  remaining  in  the  intestinal  tract  after  an  ill- 
ness of  this  nature,  which,  under  the  influence  of  such  a  favorable 
culture-medium  as  milk  take  on  renewed  activity,  and  the  whole  ill- 
ness may  be  repeated,  perhaps  with  greater  severity  than  the  original 


ACUTE   GASTRO-ENTERIC   INFECTION  I95 

one,  if  the  milk-feeding  is  persisted  in.  I  have  repeatedly  seen  in  con- 
sultation infants  who  were  having  what  was  called  a  relapse.  What 
they  did  have  was  a  reinfection  with  all  the  symptoms  as  severe  or 
more  severe  than  those  of  the  first  infection,  and  all  because  of  a  lack 
of  appreciation  of  the  necessity  of  great  care  in  resuming  milk.  To 
avoid  mistakes  in  feeding  at  this  time,  as  well  as  early  in  the  disease, 
all  directions  should  be  carefully  written.  Nurses  and  mothers  who 
think  the  physicians  are  over-cautious  and  pity  the  hungry  child 
are  very  hable  to  forget  oral  instructions  and  give  more  milk  than  is 
ordered.  I  always  tell  these  people  that  when  an  order  is  disobeyed 
the  responsibility  is  theirs.  If  the  small  amount  of  milk  agrees  it 
may  gradually  be  increased  by  the  addition  of  one-half  ounce  to 
each  feeding  every  two  or  three  days.  Rarely,  however,  will  it 
be  possible  or  wise  to  attempt  to  give  for  the  remainder  of  the 
summer  as  strong  a  food  mixture  as  was  taken  before  the  illness. 
In  milk-feeding  at  this  time  super-fat  must  not  be  used.  Either 
full  milk  or  skimmed  milk  is  given.  If  there  is  a  tendency  to  relaxa- 
tion of  the  bowels  with  frequent  passages  I  order  skimmed  milk  to 
be  used.  Whether  the  food  shall  be  pasteurized,  sterihzed,  or  raw 
depends  upon  the  conditions  referred  to  under  pasteurization  and 
sterilization  (page  iii).  Every  summer  I  have  infants  under  my 
care  who  after  an  attack  of  diarrhea  cannot  take  even  as  small  an 
amount  of  cow's  milk  as  one-half  ounce  in  each  feeding.  Not  a  few 
of  the  marasmic  out-patient  infants  belong  to  this  class.  After  a 
sharp  intestinal  infection  with  inability  thereafter  to  take  a  nutritious 
diet,  a  wet-nurse  may  be  secured  for  the  well-to-do,  but  the  wet- 
nurse's  milk  will  not  always  agree,  as  I  have  repeatedly  found. 
Children  who  have  been  very  ill  with  any  of  the  severe  forms  of 
acute  intestinal  diseases  of  summer  have,  as  a  result,  a  very  weak 
fat-capacity,  and  the  wet-nurse's  milk,  with  its  3  or  4  percent  of  fat  in 
some  instances,  produces  sufhcient  diarrhea  to  require  its  discontinu- 
ance. When  employing  the  wet-nurse  in  such  cases  it  is  best  never 
to  permit  the  child  to  have  the  full  allowance  of  breast-milk  at  first. 
For  a  child  from  three  to  six  months  of  age,  for  example,  it  is  wise  to 
give  him  two  or  three  ounces  of  barley-water  or  a  5  percent  milk-sugar 
water  before  each  nursing,  so  that  he  will  be  satisfied  with  two  or 
three  ounces  of  the  breast-milk.  When  cow's  milk  cannot  be  given 
and  the  nurse's  milk  does  not  agree,  or  where  for  any  reason  a  wet- 
nurse  is  not  possible,  we  are  called  upon  to  furnish  other  means  of 
nutrition,  and  this,  with  our  available  resources,  will  not  be  of  a  very 
high  order  for  infants  under  one  year  of  age.  The  animal  broths  are 
of  very  httle  service.  They  contain  but  httle  nourishment  even  if 
given  in  considerable  quantity.  They  produce  a  decided  laxative 
effect  on  convalescents  from  diarrhea.  Their  only  use  is  in  giving 
small  quantities,  an  ounce  or  two  added  to  the  gruel  to  make  it  more 
palatable. 


196  GASTRO-ENTERIC    DISEASES 

Strong  starchy  foods  cannot  be  digested  in  sufficient  amount 
to  maintain  the  nutrition.  It  is  under  such  conditions  that  dex- 
trinizing  processes  (page  118)  are  of  considerable  service.  The 
starch  is  thus  converted  into  mahose,  which  is  readily  assimilable. 
Here,  as  in  the  broth,  the  relaxing  effect  of  the  food  on  the  intestine 
may  be  felt,  frequent  bowel  evacuations  being  a  possible  result. 
The  dextrinizcd  gruels,  however,  are  always  worthy  of  trial,  and 
they  have  been  of  considerable  service  in  many  cases  as  a  substitute 
for  cow's  milk.  When  breast-milk  is  impossible,  canned  condensed 
milk  usually  answers  better  than  any  other  means  of  nutrition.  It 
is  much  more  easy  of  digestion  than  is  fresh  cow's  milk,  as  is  well 
known.  It  is  added  in  small  quantities  at  first  to  the  cereal  water 
made  from  barley,  rice,  or  granum.  No.  i  strength  being  employed. 
(See  formulary,  page  123.)  One-half  dram  may  be  added  to  every 
second  feeding  for  the  first  day.  The  following  day  this  amount 
may  be  added  to  every  feeding.  It  usually  will  be  well  taken  and 
well  digested.  It  is  gradually  increased  until  two,  three,  or  four 
drams  are  added  to  each  feeding.  In  not  a  few  cases  the  combina- 
tion of  condensed  milk  and  cereal  diluent  must  furnish  the  nourish- 
ment for  the  remainder  of  the  heated  term.  With  the  advent  of 
cooler  weather,  one  ounce  of  weak  cow's  milk  with  the  cereal  diluent 
may  be  substituted  for  one  of  the  regular  feedings,  which  later  may 
gradually  be  increased  one-half  or  one  ounce  at  a  time  until  the  cow's 
milk  comprises  one-third  of  the  food  mixture.  When  this  point  is 
reached  an  attempt  may  be  made  to  replace  with  cow's  milk  an- 
other feeding  of  the  condensed  milk.  In  this  way  by  carefully 
watching  the  case  a  gradual  replacing  of  the  condensed  milk 
by. fresh  cow's-milk  feeding  may  successfully  be  brought  about 
until  cow's  milk  only  is  given. 

After  the  first  year,  similar  methods  may  be  followed  if  neces- 
sary, although  at  this  age  cow's  milk  will  usually  be  tolerated 
earlier  and  other  means  of  feeding  than  the  milk  may  be  brought 
into  use.  Zwieback,  bread  crusts,  and  scraped  beef — two  or  three 
teaspoonfuls  a  day — will  often  be  taken  without  inconvenience 
when  milk  in  sufficient  amount  for  proper  nutrition  disagrees. 
At  this  age  the  gruels  also  may  be  made  stronger;  No.  2  or  No.  3 
(see  formulary,  page  124)  will  often  be  well  borne.  An  important 
point  to  be  remembered  in  feeding  convalescents  from  an  acute 
gastro-enteric  disorder  is  that  the  food  must  not  be  forced,  and 
that  the  child  must  be  fed  only  in  accordance  with  his  digestive 
capacity.  This  can  best  be  determined  by  watching  the  temperature 
and  the  stools.  The  gruels  as  substitute  feedings,  whether  alone  or 
combined  with  condensed  milk,  may  be  given  in  quantities  equal  to 
those  which  the  child  was  accustomed  to  take  in  health,  but  they 
may  be  given  at  more  frequent  intervals,  never,  how'ever,  oftener 
than  every  two  hours.     A   child   who  has  been  fed  at  four-hour 


ACl'TE    ENTERIC    INFECTION  I97 

intervals  may  take  the  substitute  at  three-hour  intervals.  If  fed 
at  three-hour  intervals,  he  may  get  the  substitute  at  two  or  two  and 
one-half  hour  intervals.  When  constipation  follows  a  sharp  attack 
of  diarrhea,  an  enema  must  be  used  not  oftener  than  once  in  twenty- 
four  hours.  The  patient  should  not  be  given  a  laxative  unless  there 
is  fever  for  several  days  after  the  acute  symptoms  have  subsided. 

ACUTE  ENTERIC  INFECTION 

Acute  enteric  infection  is  of  two  clinical  forms  and  is  distinguished 
from  gastro-enteric  infection  by  the  absence  of  vomiting.  As  with 
gastro-enteric  infection,  while  it  may  be  acute  in  character,  it 
can  hardly  be  considered  the  primary  illness,  as  it  is  usually  pre- 
ceded by  a  latent  type  of  intestinal  indigestion.  The  onset  of  the 
urgent  symptoms  oftentimes  is  so  sudden  and  so  severe  that  it  is 
regarded  as  the  commencement  of  the  illness.  The  prostration 
may  be  extreme,  the  temperature  high — 105°  to  106°  F.  The 
eyes  are  sunken  and  the  face  is  drawn  and  pinched.  Convulsions 
and  muscular  twitchings  are  often  present.  In  institution-infants 
I  have  seen  death  take  place  in  less  than  twenty-four  hours  as  a 
result  of  the  profound  toxemia.  The  milder  forms,  characterized 
only  by  a  sharp  elevation  of  temperature  and  moderate  prostration, 
respond  to  treatment  in  a  day  or  two. 

Treatment. — As  mentioned  above,  there  are  two  types  of  infec- 
tion, one  with  diarrhea  and  one  with  marked  bowel  inactivity. 
In  neither  is  there  vomiting.  In  both  types  castor  oil,  in  doses 
never  less  than  two  drams,  is  to  be  given.  This  is  followed  by 
discontinuance  of  the  milk,  whether  the  patient  is  bottle-fed  or 
nursed.  As  a  substitute,  barley-water,  rice-water,  or  granum-water 
No.  I  (page  1 24)  may  be  given  with  salt  and  sugar  added  for  fla- 
voring purposes.  An  advantage  in  the  treatment  of  these  cases  is 
that,  there  being  no  vomiting,  the  food  is  usually  well  taken 
throughout  the  entire  illness,  as  the  patient  is  ordinarily  very 
thirsty.  With  excessive  diarrhea  the  indications  for  medication  are 
the  same  as  those  given  under  Acute  Gastro-enteric  Infection  (page 
191).  Castor  oil  or  sulphate  of  soda  (page  192)  is  to  be  used 
instead  of  calomel,  at  the  beginning  of  the  illness. 

Intestinal  infection  with  defective  bowel  action  often  gives  us 
our  most  difficult  cases  and  requires  different  treatment.  In  this 
type,  poisons  generated  in  the  intestinal  contents  seem  to  be  of 
such  a  nature  as  to  cause  a  partial  paralysis  of  the  small  intestine, 
and  it  is  often  with  the  greatest  difficulty  that  an  evacuation 
can  be  induced.  So  difficult  is  it,  in  fact,  that  the  possibility  of 
an  acute  peritonitis  or  an  intussusception  is  thought  of  by  the 
physician.  It  is  very  necessary  to  maintain  bowel  action  and  to 
prevent  the  accumulation  of  gas,  which  by  its  distention  of  the 
intestine  increases  the  tendency  to  constipation.     Several  cases  of 


198     •  GASTRO-ENTERIC   DISEASES 

this  nature  with  high  temperature,  sluggish  bowel  action,  and  intense 
prostration  are  seen  by  me  every  year. 

A  case  in  point  came  under  my  observation  during  the  past  sum- 
mer. A  female  infant  nine  months  of  age  had  been  a  most  difficult 
feeding  case.  In  July  she  was  taken  with  sudden  high  fever  (105° 
F.)  and  convulsions,  which  were  followed  by  muscle  twitchings, 
head  rolling,  and  marked  prostration.  The  temperature  was  uninflu- 
enced by  local  means,  although  there  was  no  diarrhea  or  vomiting. 
The  attending  physician,  anticipating  intestinal  infection,  gave  calo- 
mel in  divided  doses  with  frequent  bowel  irrigations.  Foul-smell- 
ing fecal  material  came  away  with  the  irrigation,  but  the  temperature 
and  the  nervous  symptoms  persisted;  in  fact,  the  condition  became 
worse.  I  first  saw  the  child  when  she  had  been  ill,  perhaps  ten  or 
twelve  hours,  and  directed  that  one-half  ounce  of  castor  oil  and  a 
high  irrigation  of  normal  salt  solution  at  80°  F.  be  given.  As  a  result 
of  the  treatment  there  was  one  small  green  movement  in  addition 
to  what  came  away  with  the  irrigation,  which  was  considerable. 
The  patient  was  relieved  somewhat  and  the  nervous  symptoms 
measurably  subsided,  though  the  temperature  still  ranged  between 
104°  and  105°  F.  As  a  result  of  the  calomel,  one  and  one-half  grains 
having  been  given,  and  the  ounce  of  oil,  a  free  diarrhea  was  looked  for. 
It  did  not  appear,  however.  I  then  directed  that  one-half  ounce 
of  castor  oil  be  given  daily  in  addition  to  the  irrigations  every  eight 
hours.  This  was  followed  by  a  slight  improvement  in  the  symptoms, 
but  it  required  five  days  of  the  treatment,  one-half  ounce  of  oil  and 
one  grain  of  calomel  being  given  daily,  with  abdominal  massage, 
before  the  resulting  peristalsis  was  sufficient  to  relieve  the  intestine 
of  its  contents.  After  the  establishment  of  free  bowel  action,  the 
child  recovered. 

A  similar  case  which  resulted  fatally  was  seen  in  consultation. 
In  this  case,  a  girl  eight  years  old,  the  toxemia  was  intense.  There 
appeared  to  be  almost  complete  paralysis  of  the  small  intestine. 
Only  small,  very  foul  evacuations  could  be  induced,  in  spite  of  the 
most  active  local  and  internal  measures.  The  child  died  from 
toxemia,  before  free  bowel  action  could  be  established. 

The  management  of  these  cases  of  the  inactive  type  is  partially 
illustrated  in  the  histories  above  given.  Our  efforts  are  to  be  directed 
toward  supporting  the  patient  by  the  use  of  stimulation,  hypoder- 
mically  or  by  the  stomach,  and  by  the  use  of  a  non-milk  diet,  power- 
ful laxatives,  and  frequent  colon  flushings.  Castor  oil  will  often 
need  to  be  given  repeatedly  and  should  be  given  freely — at  least 
one-half  ounce  every  twelve  hours — until  four  or  five  passages  in 
twenty-four  hours  result.  While  the  fever,  prostration,  and  bowel 
inactivity  persist,  it  is  necessary  to  continue  the  irrigations.  In 
a  few  cases,  apparently  better  results  were  secured  by  using  for  the 
irrigations  cold  water  (70°  F.  to  80°  F.)  with  the  addition  of  Epsom 
salts,  one  ounce  to  the  pint. 


ACUTE   ILEOCOLITIS  1 99 

Stimulants. — Because  of  the  tendency  to  convulsions  and  nervous 
irritability,  strychnin  should  not  be  given.  The  tincture  of  strophan- 
thus  answers  better  than  any  other  heart  stimulant.  Alcohol  should 
be  used  only  under  the  most  urgent  conditions  of  prostration. 

If  hypodermic  stimulation  is  called  for,  a  combination  of  tinc- 
ture of  strophanthus  and  brandy,  or  digitalin  and  brandy,  answers 
well.  For  a  child  six  months  of  age,  twenty  minims  of  brandy 
with  one  drop  of  tincture  of  strophanthus,  or  twenty  minims  of 
brandy  with  3^^^  grain  digitalin,  may  be  given  and  repeated  according 
to  the  requirements  of  the  case — every  two  hours  if  necessary. 
After  the  first  year,  children  may  be  given  as  much  as  y^  ^^  grain  of 
digitalin  or  two  drops  of  the  tincture  strophanthus. 

Irrigation  of  the  colon  (page  207)  is  now  a  measure  of  inestimable 
value,  both  for  its  immediate  local  effect  and  also  for  increasing  gen- 
eral peristalsis  and  thus  emptying  the  small  intestine.  An  increase  of 
the  peristalsis  is  sometimes  well  secured  by  the  following  procedure : 
After  the  colon  is  washed  with  a  normal  salt  solution  at  a  temperature 
of  95°  F.  the  tube  is  introduced  as  far  as  possible  and  eight  ounces 
of  water  at  60°  F.  is  allowed  to  escape.  The  tube  is  immediately 
removed  and  an  attempt  made  by  elevating  the  buttocks  and  press- 
ing them  together  to  have  the  child  retain  the  solution  for  a  few 
moments. 

In  using  nutrient  enemata  and  in  colon  flushings  for  purposes  of 
supplying  fluids  to  the  circulation  we  have  found  that  the  solution  is 
best  retained  when  it  is  introduced  warm — at  a  temperature  of  about 
100°  F.  The  cooler  the  solution,  the  more  quickly  is  it  expelled 
through  exciting  peristalsis.  This  fact  may  be  taken  advantage 
of  in  these  cases  of  bowel  inactivity.  After  an  enema  of  cool  water 
peristalsis  of  the  small  intestine  will  often  result  in  the  passage  of 
a  considerable  quantity  of  its  contents  into  the  colon  to  be  expelled 
later  with  the  water.  This  I  have  frequently  demonstrated.  The 
action  of  the  cool  water  will  be  further  assisted  by  maintaining 
light  abdominal  massage  after  the  tube  is  removed.  Recovery 
may  follow  the  clearing  out  of  the  intestine,  or  an  ileocolitis  may 
result,  as  in  gastro-enteric  infection.  The  process  of  transition 
may  require  but  a  surprisingly  short  time,  and  if  recovery  is  not 
prompt  an  ileocolitis  will  almost  certainly  be  the  outcome. 

Upon  resuming  the  milk  diet  the  same  precautions  relating  to 
the  use  of  cow's  milk  must  be  observed  as  referred  to  under  Acute 
Gastro-enteric  Infection  (page  194). 

ACUTE  ILEOCOLITIS. 

A  great  deal  of  confusion  has  been  occasioned  by  attempts  at 
a  nomenclature  of  the  acute  inflammatory  diseases  of  the  intestine 
which  shall  make  the  clinical  aspect  of  the  cases  fit  the  pathologic 
findings.     Differentiation,    ante    mortem,  into    catarrhal,    follicular, 


200  GASTRO-ENTERIC    DISEASES 

and  ulcerative  types  is  impossible,  as  has  been  proved  by  the  care 
and  daily  observation  in  institution  and  hospital  work  of  cases 
that  have  later  come  to  autopsy.  Consider  briefly,  for  illustration, 
the  gravest  cases,  cases  which  at  autopsy  show  most  extensive 
ulceration  of  the  intestine.  In  many  of  these  there  was  a  low 
temperature,  from  ioo°  F.  to  102°  F.,  and  the  stools  never  contained 
a  particle  of  blood.  In  others,  in  which  perhaps  considerable  blood 
was  passed  for  several  days,  there  will  be  but  a  mild  congestion 
of  the  mucous  membrane  of  the  large  intestine.  Others  will  con- 
tinue for  a  considerable  time,  from  two  to  three  weeks,  with  mod- 
erate temperature,  and  die  from  exhaustion  and  show  nothing  at 
autopsy  but  an  enlargement  of  the  solitary  follicles  with  areas  of 
congestion  in  the  lower  portion  of  the  small  intestine.  Recent 
work  in  the  bacteriology  of  the  acute  intestinal  diseases  has  added 
nothing  to  our  knowledge  as  to  the  treatment  of  the  condition, 
and  consequently  does  not  call  for  discussion  here.  Acute  ileo- 
cohtis  may  be  the  primary  intestinal  disease.  In  this  condition 
the  temperature  is  usually  considerably  elevated  at  the  commence- 
ment of  the  illness.  After  an  evacuation  of  two  or  three  undigested 
stools,  the  passages  consist  of  light-colored  mucus,  oftentimes  streaked 
with  blood,  or  they  are  of  green  mucus  and  streaked  with  blood. 
The  passages  are  small,  frequent,  and  attended  with  considerable 
pain  and  tenesmus.  I  have  repeatedly  seen  from  twenty  to  thirty 
such  passages  from  one  patient  in  twenty-four  hours.  Far  more 
frequently,  however,  this  condition  follows  an  acute  gastro-enteric 
indigestion  or  an  intestinal  infection,  the  dangers  of  which 
were  not  appreciated,  and  the  case  consequently  was  improperly 
treated,  the  lesions  produced  being  due  to  the  bacteria  and  their 
toxins,  which  had  abundant  opportunity  to  produce  pathologic 
changes  in  the  intestinal  mucous  membrane,  the  extent  of  which 
could  only  be  conjectured  during  life. 

The  duration  of  an  ileocolitis  is  longer  than  that  of  any  of  the 
intestinal  disorders  previously  mentioned.  With  the  establishment 
of  the  disease  it  is  rare  for  a  case  to  recover  under  ten  days.  It 
oftentimes  means  an  illness  of  two  or  three  weeks,  and  sometimes  a 
longer  period  must  elapse  before  the  usual  diet  may  be  resumed. 
The  temperature  range  is  variable — from  normal  to  104°  F.  There 
is  always  emaciation.  The  degree  of  prostration  is  dependent 
upon  the  amount  of  toxemia,  the  extent  of  the  lesion,  and  the  man- 
agement of  the  case,  particularly  as  relates  to  supportive  measures 
and  the  nature  of  the  nutrition. 

Treatment. — "Slilk  is  to  be  stopped  at  once,  whether  the  patient 
is  breast-fed  or  bottle-fed.  Barley-water,  granum-water,  or  rice-water 
No.  I  (see  formulary,  page  124)  constitutes  the  basis  of  diet  for  chil- 
dren under  one  year  of  age.  Older  children  may  be  given  the  No. 
2  strength.     To  these  carbohydrate  foods  may  be   added  an  ounce 


ACUTE    ILEOCOLITIS  20l 

of  chicken  or  mutton  broth,  with  salt  or  sugar,  to  make  them  more 
palatable.  It  is  well,  for  variety,  to  make  up  two  or  three  cereal 
preparations  and  alternate  their  use.  In  this  way  the  foods  will  be 
better  taken  and  for  longer  periods  than  if  but  one  is  prepared.  In 
this  form  of  substitute  feeding,  an  amount  similar  to  what  the 
child  was  accustomed  to  in  health  may  be  given,  but  the  intervals 
may  be  shorter  by  one-half  hour  or  one  hour. 

Drugs. — In  a  large  experience  with  acute  colitis  in  institution  and 
out-patient  work,  there  has  been  abundant  opportunity  to  test  the 
value  of  different  drugs  that  have  been  advocated  from  time  to  time 
for  the  disease.  Drugs  which  have  proved  of  unquestioned  value  are 
castor  oil,  calomel,  subnitrate  of  bismuth,  and  opium.  Drugs 
which  have  an  occasional  application  are  sulphur  and  the  prepara- 
tions of  tannin.  Constitutional  measures,  supportive  in  character, 
such  as  heat  and  stimulation,  are,  of  course,  used  when  indicated, 
as  in  any  severe  exhaustive  illness.  At  the  commencement  of  the 
attack,  two  drams  of  castor  oil  should  be  given.  If  this  is  not  retained, 
from  one  to  two  grains  of  calomel  should  be  given  in  divided  doses — 
one-quarter  grain  every  hour.  Bismuth  subnitrate  is  best  given 
according  to  the  suggestions  on  page  194.  The  prescription  calls 
for  ten-grain  doses.  If  black  stools  do  not  follow  its  administration, 
one  grain  of  precipitated  sulphur  is  added  to  each  dose.  To  be 
effective  the  bismuth  must  be  given  in  large  doses.  Two  or  three 
grains  at  intervals  of  two  or  three  hours  are  of  no  value.  In  cases 
over  one  year  of  age,  fifteen  to  twenty  grains  are  frequently  given 
at  two-hour  intervals.  When  there  is  much  pain  and  tenesmus 
with  frequent,  scanty,  mucous  stools,  opium  may  be  used  with 
advantage,  with  a  view  of  controlling  the  tenesmus  and  diminishing 
the  frequency  of  the  stools.  Paregoric  or  Dover's  powder  is  usually 
selected  for  this  purpose.  Dover's  powder  is  preferred  because 
of  the  absence  of  a  disagreeable  taste  and  the  convenience  of  its 
administration.  It  may  be  added  to  the  bismuth  at  each  dose, 
not  combined  with  it  in  a  prescription,  for  uncombined  it  may  at 
once  be  discontinued  or  given  in  smaller  doses  with  a  diminution 
in  the  number  of  the  stools. 

Careful  instructions  should  be  given  when  prescribing  opium. 
It  is  to  be  given  for  a  definite  purpose,  to  prevent  straining  and  the 
frequent  passages  due  to  excessive  peristalsis.  As  in  acute  intes- 
tinal infection,  particularly  if  there  is  temperature,  it  is  not  well 
to  attempt  to  reduce  the  number  of  the  stools  below  four  or  five 
in  twenty-four  hours,  and  of  course  opium  is  not  to  be  given  at  all 
unless  the  stools  are  very  frequent.  Not  a  few  cases  do  admirably 
under  the  cereal  water  diet,  castor  oil,  bismuth,  and  sulphur.  The 
amount  of  opium  that  will  be  required  in  a  given  case  may  readily 
be  determined  by  carefully  watching  the  character  and  frequency 
of  the  stools.     For  children  under  one  year  of  age,  the  dosage  of 


202  GASTRO-ENTERIC    DISEASES 

Dover's  powder  is  from  i  to  ^  grain  at  two-hour  intervals,  not  more 
than  seven  doses  being  given  in  twenty-four  hours.  From  the 
first  to  the  tenth  year,  the  dose  ranges  from  one-half  grain  to  two 
grains.  Mothers  and  nurses  are  to  be  instructed  that  when  there 
is  a  rise  in  the  temperature  or  when  the  child  becomes  drowsy  after 
its  use  the  opium  is  to  be  discontinued  or  the  dose  reduced  one-half 
— another  advantage  of  giving  it  independently.  The  younger  the 
child,  the  greater  caution  to  be  observed  in  its  use.  Tannalbin,  in 
doses  of  two  grains  in  infants,  and  from  five  to  eight  grains  in  older 
children,  is  sometimes  of  service  when  there  is  a  tendency  to  large 
watery  stools  or  stools  containing  large  quantities  of  mucus.  This 
also  may  be  given  at  the  same  time  as  the  bismuth.  When  heart 
stimulants  are  necessary,  the  tincture  of  strophanthus  is  usually 
selected.  Digitalis  is  not  well  borne  by  the  stomach,  and  for  the 
same  reason,  as  well  as  for  its  unfavorable  effect  upon  the  kidneys, 
alcohol  should  be  given  with  caution.  When  used,  it  should  be 
well  diluted  and  given  only  temporarily  during  the  urgent  period 
of  acute  toxemia.  Its  prolonged  use  invariably  interferes  with  the 
stomach  function. 

Hot  Applications. — Hot  stupes  or  hot  compresses  to  the  abdo- 
men are  often  most  grateful  to  the  patient,  when  there  is  abdomi- 
nal pain  and  tenesmus.  The  hot  applications  should  be  changed 
every  fifteen  or  twenty  minutes,  never  being  allowed  to  become  cold. 

Colon  irrigation  should  be  used  at  least  once  in  every  case  of 
colitis,  normal  salt  solution  being  employed  at  ioo°  to  105°  F. 
The  solution  should  always  be  used  warm,  as  it  has  a  pronounced 
sedative  effect  in  some  patients  when  used  in  this  way.  It  thus  may 
fulfil  two  purposes.  Whether  the  irrigation  is  repeated  or  not  must 
depend  upon  its  effect  upon  the  patient.  When  he  strains  against 
it  and  there  is  no  apparent  diminution  in  the  number  of  the  stools, 
it  should  not  be  repeated.  Frequently,  however,  the  intestine 
remains  quiet  and  the  number  of  passages  diminishes,  after  a  warm 
irrigation — 105°  to  110°  F.  In  such  cases  it  may  be  repeated  twice 
daily.  In  cases  in  which  there  is  not  an  active  IdowcI  action,  where 
decomposing  blood  and  mucus  are  removed  by  the  washing,  it  may 
be  used  once  or  twice  daily.  Only  in  the  rarest  instances  when 
there  are  high  fever  and  delayed  bowel  action  should  intestinal  irri- 
gation be  practised  oftener  than  once  in  twelve  hours.  This  line 
of  treatment  is  oftentimes  overdone,  as  is  apt  to  be  the  case  with 
any  useful  measure. 

Irrigation  should  always  be  used  for  a  definite  purpose  and 
discontinued  when  that  purpose  is  accomplished.  Every  year,  at 
the  close  of  the  heated  term,  I  see  cases  of  chronic  colitis  without 
fever  which  are  being  irrigated  two  or  three  times  daily  without 
any  indication  for  the  irrigation  other  than  the  mucous  stools.  Irri- 
gations, without  question,  help  to  keep  up  the  secretion  of  mucus, 


ACUTE   ILEOCOIJTIS  203 

for  I  have  repeatedly  seen  it  disappear  entirely  without  other 
treatment  in  a  few  days  after  the  discontinuance  of  the  irrigation. 

The  time-honored  remedy — the  injection  of  starch  and  opium — 
may  be  of  service  in  the  cases  in  which  there  is  much  tenesmus  with 
the  passage  of  small  amounts  of  blood-streaked  mucus  or  w'hen 
bloody  mucus  exudes  from  the  rectum.  In  these  cases  the  principal 
lesions  are  usually  located  in  the  sigmoid  and  rectum.  A  straight- 
pipe,  l^iard-rubber  syringe  answers  best  for  this  purpose  (Fig.  18). 
A  starch  solution  of  the  strength  of  one  dram  of  starch  to  an  ounce 
of  boiled  water  is  used.  For  infants  under  one  year  of  age  five 
drops  of  the  laudanum  may  be  added  to  two  ounces  of  the  starch 
solution  and  repeated  at  intervals  of  from  six  to  eight  hours.  Older 
children  may  be  given  from  eight  to  twelve  drops  of  the  laudanum 
with  four  ounces  of  the  starch  solution  and  repeated  in  from  four 
to  six  hours. 

Improvement  in  the  colitis  is  indicated  by  a  subsidence  of 
the  temperature,  a  change  in  the  character  of  the  stools  from 
green  or  clear  mucus  with  blood  and  scarcely  any  odor,  to 
passages  which  gradually  take  on  a  fecal  odor  and  show  the  presence 
of  feces  mixed  with  mucus.  When  it  is  felt  that  the  case  is  under 
control,  a  change  of  climate  is  most  beneficial.  A  child  who  has 
had  colitis  at  the  seashore  or  in  town,  will  invariably  have  its  recovery 
hastened  by  a  removal  inland  to  the  mountains  or  among  the  hills, 
W'here  an  open-air  life  is  to  be  insisted  upon. 

Diet  in  Convalescence. — With  a  subsidence  of  the  fever  and  an 
improvement  in  the  number  and  character  of  the  stools,  the  patient's 
troubles  are  not  over.  The  problem  of  nutrition  is  often  a  diffi- 
cult one.  The  child  has  necessarily  been  on  a  reduced  diet  for 
several  days,  oftentimes  for  two  to  three  wrecks.  If  better  nutri- 
tion than  cereal  gruels  is  not  soon  forthcoming,  the  patient  faces 
the  danger  of  malnutrition  and  marasmus,  w'hich  is  the  outcome  in 
not  a  few  of  the  badly  treated  cases  in  which  the  disease  is  not 
quickly  fatal.  The  use  of  milk  in  some  form  must  sooner  or  later 
be  attempted. 

Children  who  have  had  coHtis  bear  fat  very  badly.  The 
younger  the  child,  the  more  certain  is  this  the  case.  This  has 
been  so  forcibly  impressed  upon  me  that  I  have  discontinued 
attempts  at  feeding  these  convalescents  even  with  small  quantities 
of  whole  milk.  I  have  found  that  they  do  best  on  a  carbohydrate 
gruel  as  a  basis  of  diet,  to  w^hich  sugar  of  milk  is  added  in  the  pro- 
portion of  from  one-half  to  one  ounce  to  the  pint,  thereby  furnishing 
material  for  heat  and  energy.  To  this  sugar-cereal  combination, 
skimmed  milk  in  small  quantities  is  added,  not  over  one-half  ounce, 
and  that  to  only  one  of  the  feedings,  the  first  day  that  milk  is  given. 
If  this  causes  no  inconvenience  an  increase  of  one-half  ounce  is 
made  at  every  second  feeding  the  following  day,  and  an  increase 


204  GASTRO-ENTERIC    DISEASES 

of  one-half  ounce  at  every  feeding  the  third  day.  The  total  quantity 
of  food  given  at  each  feeding  is  to  remain  the  same,  an  equal  quan- 
tity of  the  cereal  diluent  being  removed  to  make  way  for  the  milk 
increase.  Thereafter,  if  all  goes  well,  an  increase  of  one-half  ounce 
is  made  in  each  feeding  every  day,  until  the  child  is  taking  his  daily 
feedings  of  skimmed  milk  one-half  strength.  In  some  cases  it  may 
be  found  that  the  child's  capacity  will  be  only  two  ounces  of  skimmed 
milk  at  a  feeding  with  the  cereal  water  diluent.  Here  he  must 
be  held,  perhaps  for  a  week  or  two,  before  milk  can  safely  be  advanced. 
Usually  the  younger  the  child,  the  more  difficult  will  be  the  resump- 
tion of  the  milk  diet.  After  the  first  year  the  nutrition  may  be 
assisted  by  a  thick  gruel,  such  as  No.  2  (see  formulary,  page  124), 
zwieback,  bread  crusts,  or  rare  scraped  beef — two  or  three  teaspoon- 
fuls  daily.  For  infants  under  one  year  of  age  who  cannot  take 
even  a  weak  dilution  of  skimmed  milk,  one-half  to  one  dram  of 
condensed  milk  may  be  given  in  the  cereal  water  diluent.  A  com- 
bination of  the  canned  condensed  milk  and  granum  No.  i  (page 
124)  will  usually  be  well  taken.  If  there  is  abdominal  distention 
from  starch  indigestion,  the  granum  may  be  dextrinized  (page  124). 
Barley-water  also  answers  well  as  a  diluent  for  condensed  milk. 
In  adding  canned  condensed  milk  to  the  cereal  water,  sugar  is  to 
be  omitted.  The  milk  may  be  increased  slowly  until  from  one 
to  four  drams  are  given  at  a  feeding.  Under  no  considerations, 
however,  unless  we  are  forced  to  it,  should  this  diet  be  permanent. 
After  from  two  to  four  weeks,  the  use  of  cow's  milk  should  be  at- 
tempted, replacing  one  feeding  of  the  condensed  by  a  small  amount 
of  cow's  milk,  one-half  to  one  ounce  in  the  customary  diluent.  To 
the  cow"s-milk  mixture  a  small  amount  of  cane-sugar,  twenty  to 
thirty  grains,  should  be  added,  as  the  child  has  been  accustomed 
to  the  sweet  food  furnished  by  the  canned  condensed  milk.  Obsti- 
nate constipation  sometimes  follows  recovery  from  severe  ileo- 
colitis. This  is  to  be  managed  along  the  lines  laid  down  for  the 
management  of  constipation  (page  167).  Following  an  attack 
of  ileocolitis,  the  patient  must  never  be  allowed  to  pass  twenty- 
four  hours  without  an  evacuation  of  the  bowels.  A  standing  order 
should  be  given  that  an  enema  should  be  used  when  this  does  not 
occur. 

CHRONIC  ILEOCOLITIS 
Cases  of  chronic  ileocolitis  coming  under  my  care  have  invari- 
ably been  preceded  by  acute  attacks,  those  that  were  unusually 
severe  or  that  were  badly  managed.  These  cases  represent  one  of 
the  forms  of  malnutrition,  but  are  of  such  a  nature  as  to  require 
special  consideration.  The  patient  is  emaciated,  the  skin  is  dry 
and  rough,  the  circulation  is  poor,  the  extremities  are  cold,  and  the 
temperature  often  subnormal,  with  an  occasional  sharp  rise.  The 
abdomen  is  always  distended  with  gas.     The  stools  usually  are  loose, 


CHRONIC    ILEOCOLITIS 


205 


number  three  to  four  daily,  and  contain  mucus  in  considerable 
amount.  The  mucus  may  be  absent  for  two  or  three  days,  when  there 
will  be  a  rise  in  temperature  to  from  102°  F.  to  105°  F.,  when  large 
quantities  will  be  passed  with  a  very  foul  odor.  The  nervous  symp- 
toms are  usually  marked.     The  child  is  irritable  and  sleeps  poorly. 

In  assuming  the  care  of  one  of  these  cases  it  is  well  to  inform 
the  parents  that  a  rapid  improvement  is  not  to  be  looked  for. 
A  case  under  my  care  at  the  present  time,  aged  three  and  one- 
half  years,  and  which  is  now  making  satisfactory  progress,  weighs 
but  twenty-three  pounds — two  pounds  less  than  when  she  was 
eighteen  months  old.  During  the  first  six  months  that  I  treated 
her,  there  was  very  slow  improvement,  in  spite  of  every  advantage 
that  care  and  change  of  climate  could  afford.  The  management  con- 
sists in  diet,  change  of  climate  when  possible,  and  supportive  measures. 
It  is  for  the  physician  to  find  out  in  a  given  case  what  means  of 
nutrition  is  best.  These  cases  vary  considerably  in  their  digestive 
possibilities,  with  the  exception  that  they  all  bear  fat  foods  badly. 

Treatment. — Diet. — Chronic  colitis  is  very  fatal  in  young  infants 
and  but  few  survive.  Practically,  the  only  hope  for  infants  under 
one  year  of  age  is  breast-milk,  which  at  first  must  be  given  in 
small  quantities.  Sugar-water  should  be  given  before  the  nursing. 
These  young  infants  do  not  do  well  on  starchy  foods  unless  they 
have  been  dextrinized  (page  119);  when  predigested,  they  may  have 
too  laxative  an  effect  and  should  be  given  in  small  quantities.  The 
use  of  starch,  therefore,  in  these  cases,  for  a  considerable  time  at 
least,  is  limited. 

For  older  children,  after  the  first  year,  skimmed  milk,  rare  scraped 
meat,  junket,  and  coddled  white  of  egg  or  raw  egg  usually  answer  best. 

In  children  under  one  year  of  age  for  whom  the  breast  is  not 
available,  the  white  of  egg  may  be  beaten  up  and  given  in  skimmed 
milk  or  in  dextrinized  gruel.  No.  3  (page  124),  if  it  agrees,  or  in  plain 
water  with  salt  added.  The  whites  of  two  or  three  eggs  may  thus 
be  given  daily  with  benefit.  Zwieback  or  bread  crusts  may  be  given 
in  small  quantities.  These  cases  readily  develop  the  alcohol  habit, 
so  that  if  given  at  all,  its  use  should  not  be  long  continued.  The 
feedings  are  necessarily  more  frequent  than  in  well  children.  I 
usually  feed  them  five  times  a  day — at  four-hour  intervals. 

Enemata. — There  should  be  a  standing  order  for  an  enema  after 
every  interval  of  twenty-four  hours  if  no  movement  from  the  bowel 
takes  place  during  that  time.  Absence  of  bowel  movement  in  these 
cases  almost  invariably  means  fever,  prostration,  and  perhaps  convul- 
sions. If  there  is  a  tendency  to  constipation,  as  there  will  be  in  some 
cases,  some  laxative,  such  as  magnesia  or  the  aromatic  fluidextract 
of  cascara,  should  be  given  daily  in  sufficient  amount  to  insure  at 
least  one  free  evacuation. 

Irrigation  of  the  colon  is  not  to  be  used  as  a  routine  measure.     It 


206  GASTRO-ENTERIC    DISEASES 

is  indicated  whenever  there  is  a  rise  in  temperature,  even  though 
the  bowels  moved  but  a  few  hours  previously.  A  laxative,  prefer- 
ably castor  oil  or  calomel,  is  given  also.  The  further  treatment  calls 
for  salt  baths,  oil  inunctions,  and  the  open-air  life  referred  to  in  the 
section  on  Malnutrition  (page  156) 

MUCOUS  COLITIS 

Attention  has  elsewhere  been  called  to  the  necessity,  in  some 
of  the  diseases  of  children,  of  ignoring  what  appears  to  be  a  local 
manifestation  of  disease,  and  treating  the  patient  along  dietetic 
and  hygienic  lines.  This  necessity  is  in  no  disease  better  illustrated 
than  in  mucous  colitis,  a  disease  fortunately  rare  in  children,  yet 
seen  with  sufficient  frequency  to  warrant  our  attention.  The  patients 
who  have  come  under  my  care  have  invariably  been  of  a  pronounced 
neurotic  type,  usually  of  neurotic  ancestry,  and  invariably  from 
a  neurotic  environment. 

In  children  with  mucous  colitis  the  appetite  is  capricious,  the 
bowels  are  usually  constipated,  the  child  is  chronically  irritable,  and  he 
is  apt  to  complain  of  ill-defined  pains  in  the  abdomen,  which  are  never 
very  severe  and  are  not  necessarily  associated  with  the  taking  of 
food.  There  is  usually  slight  generalized  pain  on  pressure.  One  of 
my  cases  under  treatment  at  the  present  time,  a  child  four  years 
of  age, — the  most  pronounced  case  that  I  have  ever  had  under  my 
care, — has  never  had  the  slightest  evidence  of  pain  on  pressure  or 
otherwise.  With  the  dejections,  there  is  usually  mucus  in  consid- 
erable amount,  occasionally  passed  in  large  masses,  at  other  times 
in  long  tenacious  strings,  sometimes  referred  to  as  "ropy."  There 
may  be  several  consecutive  days  in  which  little  or  no  mucus  will 
be  passed,  then  large  amounts  of  it  will  suddenly  appear. 

The  disease  rarely  follows  an  acute  inflammatory  process  in  the 
intestine.  In  the  majority  of  instances  the  previous  history  has 
been  one  of  obstinate  constipation  in  a  markedly  neurotic,  underfed 
child,  the  constipation  having  existed  perhaps  during  his  entire  life. 
Almost  without  exception  the  treatment  has  been  by  the  use  of  colon 
irrigations,  using  various  kinds  of  astringents,  such  as  solutions  of 
tannic  acid,  nitrate  of  silver,  etc. 

Treatment. — Local  Measures. — The  method  of  treatment  to  which 
these  cases  most  quickly  respond  is  to  discard  those  local  measures 
which  often  act  as  irritants  to  the  intestinal  mucous  membrane. 
Usually  as  a  result  of  previous  treatment  and  because  of  the 
nature  of  the  disease  the  constipation  is  most  obstinate.  For  this 
I  use  the  olive  oil  injection  at  bedtime,  two  to  three  ounces,  the 
tube  being  introduced  eight  inches  into  the  bowel  (page  174). 
After  breakfast  on  the  following  morning  the  child  is  placed  at 
stool,  and  if  no  passage  occurs  in  fifteen  minutes  a  glycerin  sup- 
pository is  inserted.     By  this  means  one  passage  daily  is   usually 


COLON    IRRIGATION  207 

insured,  and  this  ordinarily  is  all  that  is  required.  Should  this 
fail,  from  one  to  two  drams  of  the  aromatic  fluidextract  of  cas- 
cara  should  be  given  at  bedtime  in  addition,  the  medication  being 
discontinued  as  soon  as  it  is  demonstrated  that  an  evacuation  will 
occur  without  it.  Local  measures  other  than  those  suggested  for 
constipation  are  not  to  be  employed. 

Diet. — Not  infrequently  these  patients  have  been  taking  a  consid- 
erable amount  of  milk.  This  is  immediately  discontinued.  In  its 
place  malted  milk  or  whey  is  given  as  a  drink.  The  further  diet 
consists  of  whole-wheat  bread,  animal  broths,  cereals  cooked  three 
hours,  eggs,  poultry,  red  meat,  stewed  fruit,  and  fruit-juices.  Spinach 
and  asparagus  are  the  only  vegetables  allowed  at  the  beginning 
of  the  treatment,  and  these  by  all  means  should  always  be  given. 
Purees  of  peas,  beans,  and  lentils  are  given  freely.  The  use  of 
butter  is  also  encouraged.  I  endeavor  to  have  the  patient  take 
three  ounces  daily.     It  may  be  given  on  bread  or  on  the  cereal. 

Drugs. — Strychnin  and  nux  vomica  appear  to  exert  a  very  benefi- 
cial influence  on  these  cases.  The  combination  of  nux  vomica  and 
quinin  has  been  very  satisfactory.  For  a  child  from  five  to  ten  years 
of  age  the  following  should  be  ordered: 

I^.     Tincturae  nucis  vomicae gtt.  xc 

Quininge  bisulphatis gr.  be 

M.     Div.  et  ft.  capsulae  No.  xxx. 
Sig. — One  capsule  after  each  meal. 

A  child  suffering  from  mucous  colitis  invariably  shows  malnu- 
trition to  a  considerable  degree.  For  details  as  to  sleep,  rest,  exer- 
cise, and  baths,  all  of  which  are  more  important  than  medication, 
the  reader  is  referred  to  the  section  on  Tardy  Malnutrition  (page  158). 

COLON  IRRIGATION 
Colon  irrigation  was  brought  prominently  into  use  about  fifteen 
years  ago  as  a  remedy  in  the  intestinal  summer  disorders  of  young 
children.  While  unquestionably  its  usefulness  in  this  respect  has 
been  overestimated,  and  the  irrigation  overdone,  in  selected  cases 
it  is  of  great  service.  Because  a  child  has  a  summer  diarrhea, 
a  colitis,  or  any  disorder  of  the  intestine,  it  does  not  follow  that 
irrigation  is  indicated,  or  that  he  will  be  benefited  thereby.  A 
child  who  is  having  a  passage  from  the  bowels  every  half  hour  or 
hour  is  not,  according  to  my  observation,  a  fit  subject  for  irrigation. 
The  colon  is  kept  empty  by  the  active  peristalsis  and  the  washing 
will  remove  nothing  more  than  a  few  shreds  of  mucus.  The  cases 
benefited  by  irrigation  are  those  in  which  peristalsis  is  not  particu- 
larly active.  When  a  child  is  running  a  temperature  of  102°  F. 
and  over,  with  five  or  six  green  mucous  passages  daily,  one  or  two 
colon  irrigations  a  day  will  unquestionably  be  of  service  in  removing 
the  offending  material  from  the  intestine. 


208 


GASTRO-ENTERIC   DISEASES 


Every  year  we  see  a  few  cases  of  intestinal  infection,  particularly 
those  of  a  very  acute  type,  in  which  there  is  high  fever,  intense 
prostration,  and  infrequent  bowel  action.  Occasionally  we  see  a 
case  of  this  sort  in  -which  there  is  no  movement  whatever  without 
assistance.  In  such  cases  colon  irrigation  is  of  inestimable  value, 
and  may  be  used  with  advantage  as  often  as  once  in  six  or  eight 
hours.     The  washing,  even  if  properly  conducted,  is  apt  to  be  strongly 

objected  to  by  the  patient 
and  should  be  completed 
as  soon  as  possible.  Too 
frequent  irrigations,  with 
strong  medicated  solu- 
tions, may  keep  up  the 
mucous  discharge  indefi- 
nitely. In  a  few  children 
the  resistance  with  strain- 
ing is  so  marked  and  so 
continuous  that  irrigation 
is  impossible.  These  are 
usually  children  who,  on 
account  of  the  excessive 
peristalsis,  do  not  require 
irrigation. 

The  irrigation  is  con- 
ducted as  follows:  Nor- 
mal salt  solution  at  95°  F. 
is  ordinarily  used  and  a 
quart  usually  suffices.  If 
there  is  a  great  deal  of 
mucus  and  blood  a  i  per- 
cent tannic  acid  solution 
is  better.  The  irrigation 
should  be  continued  until 
the  solution  returns  clear. 
The  temperature  of  the 
solution  may  be  varied 
with  advantage,  depend- 
ing upon  the  nature  of 
the  case;  thus,  in  cases 
with  subnormal  temperature  and  intense  prostration,  cases  of  the 
so-called  "algid  "  type,  the  solution  at  110°  F.  will  act  as  a  decided 
stimulant.  It  raises~the  temperature,  improves  the  pulse  and  the 
general  condition  of  the  patient.  In  cases  with  high  fever — 105°  F. 
or  106°  F. — a  cold  solution  answers  better.  I  have  repeatedly  used 
it  as  low  as  70°  F.,  and  have  often  found  that  an  irrigation  with  four 
pints  of  water  at  70°  F.  would  reduce  a  temperature  three  degrees. 


Fig.  21.— Colon  Irrigation. 


INTESTINAL   OBSTRUCTION  209 

For  irrigation,  a  soft-rubber  catheter,  No.  18  American,  is  best, 
for  the  reason  that  its  walls  are  stiff  and  the  tube  does  not  easily 
bend  upon  itself,  as  is  apt  to  be  the  case  when  an  ordinary  catheter 
is  used.  Should  this  occur,  the  water  may  escape  an  inch  or  two 
within  the  rectum,  and  obviously  be  of  no  service.  When  the 
tube,  well  lubricated,  has  been  introduced  for  nine  inches,  the  tip 
will  have  passed  into  the  descending  colon,  and  further  introduc- 
tion will  be  of  no  advantage.  In  order  to  be  sure  that  it  is  in 
the  colon,  gentle  palpation  over  the  left  side  of  the  abdomen  will 
enable  one  readily  to  locate  it.  The  tube  is  attached  to  an  ordinary 
fountain  syringe  by  passing  the  distal  end  over  the  sinallest  rectal 
tip,  which  is  a  part  of  the  outfit  of  every  fountain  syringe.  The 
bag  should  be  held  not  over  three  feet  above  the  child's  body. 
When  the  water  is  allowed  to  run,  the  buttocks  should  be  pressed 
together,  for  by  so  doing  we  hope  to  flush  the  entire  large  intestine. 
If  this  can  be  done,  the  irrigation  will  be  most  efficient. 

In  this  connection  I  would  mention  a  beneficial  effect  of  irriga- 
tion, of  which  we  hear  but  little,  viz.,  the  absorption  of  a  portion 
of  the  salt  solution  by  the  intestines  (page  199).  Not  a  few  of  the 
intestinal  cases  have  a  very  limited  food  capacitv.  As  a  result 
of  the  vomiting  and  very  frequent  liquid  stools,  the  body  is  thor- 
oughly drained  of  fluids.  In  such  cases,  after  the  washing  is  com- 
pleted, I  endeavor  to  have  the  child  retain  as  much  as  possible  of  the 
normal  salt  solution.  As  an  aid  to  this,  the  child  should  be  placed 
on  its  left  side  with  the  buttocks  elevated  and  the  tube  introduced 
well  up  into  the  descending  colon.  The  buttocks  should  be  pressed 
together  so  as  to  assist  the  child  in  retaining  the  water  after  it  has 
passed  into  the  bowel.  When  a  half  pint  or  a  pint  has  passed  in, 
the  tube  should  quickly  be  withdrawn  and  the  child  kept  for  half 
an  hour  in  a  recumbent  position  with  the  buttocks  elevated. 

INTESTINAL  OBSTRUCTION 

Agencies  impeding  or  preventing  the  normal  evacuation  of  the 
bowels  may  be  either  congenital — due  to  a  malformation  of  some 
portion  of  the  intestinal  tract — or  they  may  be  acquired.  Congeni- 
tal malformation  may  be  found  in  any  portion  of  the  tract,  but 
it  is  most  frequently  seen  at  or  near  the  outlet  or  in  the  region  of 
the  duodenum.  Silverman  states  that  42  percent  of  the  cases  of 
congenital  malformation  are  in  the  duodenum.  When  it  occurs  at 
the  outlet,  there  may  be  an  imperforate  anus,  or  the  absence  of, 
or  atresia  of,  the  lower  portion  of  the  rectum. 

The  treatment  of  this  deformity  is  surgical.  The  most  common 
cause  of  acquired  obstruction  is  intussusception  (page  211).  Periton- 
itis, both  acute  and  chronic,  may  cause  a  cessation  of  bowel  action. 
Tuberculous  peritonitis,  through  the  formation  of  fibrinous  bands  and 
adhesions,  may  cause  sufficient  constriction  of  the  gut  to  prevent  the 
14 


2IO  GASTRO-ENTERIC    DISEASES 

passage  of  the  intestinal  contents.  In  such  cases  also,  relief  is  best 
furnished  by  surgical  measures.  Acute  infective  peritonitis  (page 
469),  producing  a  complete  cessation  of  peristalsis,  acts  indirectly  as 
a  means  of  preventing  the  normal  passage  of  the  bowel  contents. 
The  infection  is  usually  secondary.  Operative  procedures  may  be 
attempted,  but  all  of  my  cases  have  been  fatal.  Two  were  operated 
on,  as  it  was  feared  there  might  be  an  intussusception  or  a  volvulus. 
In  one  case  peritonitis  followed  pneumonia,  the  infection  being 
due  to  the  pneumococcus. 

Strangulated  hernia  is  a  condition  by  no  means  difficult  of  diag- 
nosis and  demands  prompt  surgical  relief. 

Illustrative  Cases. — Fecal  impaction  was  found  in  two  of  my 
cases  with  intestinal  obstruction.  Both  were  seen  in  consultation. 
There  had  been  prolonged  constipation  with  insufficient  evacuations 
owing  to  neglect  on  the  part  of  the  attendants.  The  duration  of 
the  condition  it  is  impossible  to  state,  as  the  children  were  permitted 
to  go  to  the  toilet  alone,  and  as  both  were  under  five  years  of  age, 
but  little  dependence  could  be  placed  upon  their  testimony.  In 
both  cases  enemata  and  cathartics  had  been  tried  in  vain.  There 
was  vomiting  and  slightly  distended  abdomen.  There  was  no  fever 
and  no  marked  tenderness  on  pressure.  In  my  opinion,  the  vomit- 
ing was  due  chiefly  to  the  medication,  for  it  ceased  when  drugs 
were  discontinued.  Both  children  responded  to  massage  and  in- 
jections of  molasses  and  water.  Eight  ounces  of  molasses  and 
eight  ounces  of  water  were  introduced  by  means  of  a  rectal  tube 
at  intervals  of  four  hours.  One  case  was  relieved  after  the  second 
injection,  the  other  after  the  fourth.  Massage  was  early  brought 
into  use.  This  was  given  for  thirty  minutes  and  repeated  after 
an  interval  of  ninety  minutes.  The  interrupted  massage  was  con- 
tinued until  an  evacuation  occurred. 

An  unusual  case  of  intestinal  obstruction  was  seen  in  a  wretched, 
premature  infant,  five  months  of  age,  weighing  about  seven  pounds. 
The  child  had  a  congenital  heart  lesion  and  deformities  of  the  ears. 
It  was  suddenly  taken  ill  with  vomiting  and  the  passage  was  pale 
mucus  streaked  with  blood.  No  tumor  could  be  felt,  but  a  diag- 
nosis of  intussusception  was  made  and  the  abdomen  opened.  At  the 
site  of  the  obstruction  was  a  Meckel's  diverticulum  which  had  twisted 
the  gut  so  as  to  prevent  the  passage  of  gas  or  intestinal  contents. 

Intra-abdominal  tumors,  such  as  sarcoma  of  the  kidney  and  hydro- 
nephrosis, may  cause  obstruction  through  pressure  on  the  intestine. 

APPENDICITIS 

Appendicitis  in  children  is  so  essentially  a  disease  requiring  sur- 
gical interference,  that  little  need  be  said  of  it  here.  Inflammation 
of  the  appendix  is  a  more  serious  condition  in  the  child  than  in  the 
adult  and  less  delay  in  surgical    procedure  is  permissible.     There 


INTUSSUSCEPTION  2  1 1 

is  a  much  greater  tendency  toward  suppuration  than  in  the  adult, 
because  of  the  presence  of  a  lymphoid  structure  within  the  appendix. 
Treatment. — Until  surgical  procedure  can  be  brought  into  use,  the 
patient  should  be  kept  as  quiet  as  possible  in  bed.  Fluid  diet  in  the 
form  of  diluted  milk  and  gruel  should  be  given.  A  saline  laxative 
should  be  used  to  keep  the  bowels  open.  Citrate  of  magnesia  is  palat- 
able and  is  usually  well  taken  by  most  children.  An  ice-bag  should  be 
placed  over  the  appendix  and  kept  constantly  applied.  If  for  any 
reason  operation  is  inadvisable  or  impossible,  the  broth  and  gruel 
diet,  the  ice-bag,  and  the  recumbent  position  should  be  continued 
until  every  indication  of  pain  and  rigidity  of  the  rectus  has  disap- 
peared. If  the  patient  has  the  good  fortune  to  recover,  a  suitable 
time  should  be  selected  for  an  interval  operation;  for  a  second 
attack  is  very  liable  to  follow  and  is  always  more  severe  than  the  first, 
abscess  formation  being  very  probable.  Further,  the  second  attack 
may  occur  when  the  child  is  otherwise  ill,  or  is  away  on  his  vacation 
or  at  school,  where  the  necessary  surgical  skill  cannot  be  obtained. 

INTUSSUSCEPTION 

Intussusception  is  such  a  distinctly  surgical  affection  that,  like 
appendicitis,  it  requires  but  little  notice  here.  When  there  are 
clinical  signs  of  persistent  vomiting  with  bile-stained  vomitus; 
when  there  is  marked  prostration  with  low  temperature;  when 
the  stools  consist  largely  of  white  mucus  streaked  with  blood  or 
perhaps  with  moderate  hemorrhage,  all  characterized  by  sudden 
and  severe  onset,  whether  a  tumor  is  present  or  not,  a  surgical 
proposition  in  a  great  majority  of  the  cases  is  before  us.  Of  the 
fifteen  cases  I  have  seen,  all  but  one  occurred  in  well-nourished 
nursing  babies,  in  whom  there  had  been  no  previous  illness,  other 
than  constipation.  The  youngest  nursing  baby  was  two  weeks 
old;  the  oldest,  ten  months.  The  older  child  was  two  and  one- 
half  years  of  age.  The  high  mortality  reported  by  the  surgeons — . 
from  50  to  80  percent — is  due  to  two  factors :  the  tender  age  of  the 
patients  and  the  delayed  operation. 

The  cases  seen  in  consultation  and  those  seen  in  children's  hospi- 
tals usually  had  been  treated  for  something  other  than  intussuscep- 
tion. Sometimes  such  treatment  has  been  continued  for  several 
days.  By  the  time  these  cases  reach  the  hands  of  the  surgeon,  there 
may  be  extensive  adhesions,  gangrene  of  the  involved  portion  of  the 
intestine,  and  an  exhausted  child  to  deal  with. 

Reduction  by  Water-pressure. — It  is  my  custom  in  such  cases  first 
to  send  for  the  surgeon  and  then  make  one  attempt  at  reduction  by 
water-pressure:  A  well  oiled  catheter.  No.  18  American,  or  a  small  rec- 
tal tube  is  attached  to  the  small  hard-rubber  tip  of  a  fountain  syringe. 
Two  quarts  of  a  normal  salt  solution  is  placed  in  the  bag,  which  is 
hung  at  an  elevation  of  four  feet  above  the  child's  body.     The  colon, 


212  GASTRO-ENTERIC   DISEASES 

or  that  part  of  it  below  the  intussusception,  is  slowly  filled  with  a 
warm  salt  solution.  A  small  wet  towel  is  tightly  wrapped  around 
the  catheter  and  fairly  strong  pressure  made  at  the  anus  by  an 
assistant  in  order  to  prevent  the  escape  of  the  fluid.  With  the 
child  on  his  back  with  both  hands  free,  the  buttocks  are  elevated 
on  a  pillow  or  bed-pan  at  a  plane  ten  inches  above  the  shoulders. 
In  the  cases  in  which  the  tumor  is  palpable,  an  attempt  is  made, 
by  gentle  abdominal  manipulation,  to  reduce  the  intussusception. 
This  in  two  cases  I  have  thus  succeeded  in  doing. 

Illustrative  Case. — A  child  two  and  one-half  years  of  age  was 
brought  to  my  office  at  midnight  with  a  history  of  a  severe  attack  of 
colic  about  9  o'clock,  which  was  followed  by  severe  attacks  of  vomiting 
and  two  stools  of  mucus  and  blood.  Gentle  manipulation  of  the  abdo- 
men showed  a  large  sausage-shaped  tumor,  about  five  inches  long,  in 
the  left  hypochondrium,  which  I  diagnosed  as  an  intussusception. 
The  tumor  could  not  be  felt  by  rectal  examination.  Water-pressure, 
as  described  above,  with  abdominal  manipulation,  reduced  the  intus- 
susception in  a  few  minutes.  The  other  case  was  in  a  baby  nine 
months  of  age.  I  saw  the  child  in  consultation  after  the  intus- 
susception had  existed  for  six  days.  The  child  was  unconscious 
and  in  profound  collapse.  He  was  pulseless,  but  the  heart-sounds 
could  be  faintly  distinguished  by  the  aid  of  the  stethoscope.  The 
rectal  temperature  was  96°  F.  The  abdomen  was  greatly  distended. 
The  child  had  been  treated  for  cholera  infantum,  although,  for  five 
days,  nothing  but  white  mucus  tinged  with  blood  had  been  passed. 
Palpation  revealed  a  sausage -shaped  tumor  extending  along  the 
entire  left  side  of  the  abdomen,  which  in  spite  of  the  abdominal 
distention  could  easily  be  made  out  by  firm  pressure.  The  child 
was  unconscious,  so  that  there  was  no  resistance  to  the  examination. 
By  rectal  examination  the  projection  of  the  involuted  gut,  which 
resembled  the  cervix  uteri,  could  readily  be  distinguished.  The 
condition  of  the  child  precluded  all  chance  of  surgical  relief,  and 
I  hesitated  to  use  water-pressure,  fearing  that  the  gut  might 
be  gangrenous  and  a  rupture  result,  or  that  there  might  be 
adhesions  sufficient  to  prevent  reduction  and  that  the  child  might 
die  during  the  manipulations.  I  explained  the  situation  to  the 
parents,  who,  after  considerable  urging,  consented  to  a  trial  being 
made.  The  patient  was  accordingly  given  y^  grain  of  strychnin, 
one  drop  of  tincture  of  strophanthus,  and  thirty  drops  of  brandy 
hypodermatically.  The  water-pressure  was  applied  in  the  usual 
way,  and  it  was  with  the  greatest  surprise  and  with  supreme  satis- 
faction that  I  felt  the  tumor  slowly  give  way,  to  be  followed  by 
an  expulsion  of  gas  and  a  quantity  of  very  fetid  fecal  matter.  A 
hot  colon  flushing  at  110°  F.  with  a  normal  salt  solution  was  given 
a  few  minutes  later.  This  was  all  retained,  and  six  hours  later 
twelve  ounces  more  were  given.  Hot-water  bottles  and  bags  were 
placed  about  the  child.     He  had  sufficiently  revived  in  an  hour  after 


FISSURE   OF   THE    ANUS  213 

the  first  colon  flushing  to  be  able  to  swallow  diluted  brandy  and  egg- 
water,  both  of  which  were  freely  given.  A  rapid  recovery  followed. 
This  case,  to  me,  was  interesting  in  many  ways,  particularly  as  it 
emphasized  what  we  sometimes  see  in  work  among  children  when 
victory  is  snatched  from  the  jaws  of  evident  defeat — that  we  should 
never  cease  our  efforts  so  long  as  life  lasts.  It  is  my  practice  to 
make  but  one  attempt  at  reduction  by  water-pressure.  When 
this  does  not  succeed  after  a  five-minute  trial,  immediate  operation 
gives  the  patient  his  only  chance  of  recovery. 

INFLAMMATION  OF  THE  ANUS 
An  acute  painful  inflammation  of  the  anus  and  of  the  skin  sur- 
rounding it  is  frequently  seen  in  children  after  a  diarrhea  of  some 
days'  duration.  It  is  also  seen  in  weakly,  delicate  children  without 
any  marked  intestinal  disturbance.  The  inflammation  produces 
considerable  distress  during  the  passage  of  a  stool  and  is  conducive 
to  constipation,  because  the  child  soon  dreads  to  have  a  bowel 
movement  and  tries  to  avoid  it.  The  child's  nutrition  and  manage- 
ment in  general  must  first  be  carefully  looked  after,  as  suggested 
elsewhere  (page  166).  For  the  local  trouble,  the  free  use  of  hot 
water  after  each  defecation  is  necessary.  This  is  to  be  followed 
by  a  generous  application  of  an  ointment  made  as  follows: 

I^.      Ichthyoli 5j 

Unguenti  aquae  rosae oj 

Instructions  are  given  that  the  parts  are  to  be  kept  covered  with 
the  ointment,  by  applying  it  on  a  piece  of  old  linen  which  should 
be  changed  every  three  hours.  This  treatment  is  usuallv  followed 
by  prompt  relief. 

FISSURE  OF  THE  ANUS 

Anal  fissure  is  a  condition  usually  seen  in  quite  young  children. 
I  have  seen  comparatively  few  cases  in  those  over  two  years  of 
age.  Rough  manipulation  may  be  a  cause,  which  may  result  from 
the  unskilled  use  of  the  syringe  or  rectal  tube.  I  have  seen  one 
such  case.  With  very  few  exceptions,  however,  the  fissure  is  due 
to  the  stretching  of  the  parts  by  the  passage  of  large  fecal  masses, 
causing  minute  lacerations  of  the  mucous  membrane  wdthin  the 
anal  ring.  A  good  light  and  gentle  separation  of  the  buttocks 
will  usually  bring  the  laceration  into  view.  There  are  iew  more 
painful  affections.  The  vigorous  crying  preceding  and  during  the 
defecations  helps  the  mother  to  locate  the  source  of  the  trouble. 
Occasionally  the  fecal  mass  will  be  streaked  with  blood.  Caused, 
as  it  is,  by  constipation,  the  painful  nature  of  the  condition  tends 
to  delayed  bowel  action,  as  the  child  soon  learns  to  dread  a  movement, 
and  postpones  it  until  medication  or  some  manipulative  means  are 
employed  to  induce  it. 

A  few  months  ago  a  little  girl,  twenty  months  old,  was  brought 


214  GASTRO-ENTERIC   DISEASES 

to  me  because  she  cried  and  objected  to  being  placed  in  position 
for  a  bowel  evacuation,  and  cried  much  harder  during  the  evacua- 
tion. The  day  preceding  the  visit  to  my  office  the  mother  feared 
that  the  child  would  have  a  convulsion,  so  great  was  her  distress. 
Examination  of  the  rectum  showed  two  rather  small  fissures  extend- 
ing through  the  anal  mucous  membrane. 

Treatment. — Diet. — For  a  prompt  repair  of  the  fissures,  it  is  nec- 
essary to  render  the  stools  soft.  This,  in  the  bottle-fed,  is  often 
easily  accomplished  by  the  addition  of  one  of  the  malted  foods, 
either  Mellin's  food  or  malted  milk — one  or  two  teaspoonfuls  being 
added  to  the  regular  milk  mixture — or  one  feeding  of  malted  milk 
each  day  may  be  substituted  for  one  of  the  regular  feedings.  It 
may  be  used  in  the  strength  of  from  four  to  six  teaspoonfuls  in 
eight  ounces  of  milk. 

Drugs. — If  drugs  are  necessary  or  are  preferred,  one  or  two  tea- 
spoonfuls daily  of  the  milk  of  magnesia  given  in  the  milk  food  will 
answer  well. 

Local  Measures. — Proper  regulation  of  the  bowel  function,  while 
absolutely  necessary  for  a  cure  of  the  laceration,  is  not  of  itself  suf- 
ficient to  effect  permanent  relief.  The  parts  must  be  thoroughly 
washed  with  warm  water  and  castile  soap  after  each  defecation. 
After  the  washing,  and  at  three-hour  intervals  during  the  day,  25  per- 
cent of  ichthyol  in  zinc  ointment  should  be  applied  with  a  clean  index- 
finger,  which  is  introduced  well  up  into  the  anal  aperture.  If  the 
fissure  is  a  deep  one,  it  will  be  well  to  begin  the  treatment  by  cocainiz- 
ing the  parts,  using  a  3  percent  solution  of  cocain,  and  then  cauterize 
with  a  50  percent  solution  of  nitrate  of  silver,  which  is  apphed  on  a 
cotton-tipped  probe.  Twelve  hours  later  the  ichthyol  ointment  may 
be  used  as  in  the  milder  cases.  I  have  yet  to  see  a  case  which  did 
not  respond  to  the  above  treatment  if  it  was  faithfully  carried  out. 

THE  INTESTINAL  PARASITES 

The  most  common  of  the  intestinal  parasites  found  in  children 
are  of  three  types:  Ascaris  lumbricoides,  or  round-worm;  the  Ox- 
yuris  vermicularis,  or  thread-worm;  the  Taenia,  or  tape-worm. 

Round -worms. — The  round- worms,  if  in  considerable  number, 
may  produce  colic  or  constipation,  the  latter  oftentimes  alternating 
with  diarrhea  and  with  nervous  disturbance,  sometimes  of  an 
urgent  character.  In  the  great  majority  of  my  cases,  however, 
no  svmptoms  whatever  were  present,  and  the  fact  that  the  child 
had  parasites  in  the  intestine  was  first  learned  when  one  was  found 
to  have  been  passed  by  the  rectum.  In  one  of  my  cases,  in  a  child 
three  years  of  age,  there  had  been  repeated  convulsions.  The 
mother  stated  that  the  child  had  passed  a  couple  of  round-worms 
the  day  before.  I  gave  one-half  ounce  of  castor  oil,  which  was 
followed,  in  one  hour,  by  two  grains  of  santonin.  Forty- three 
large  round-worms  were  passed  during  the  next  twenty-four  hours. 


THE   INTESTINAL   PARASITES  215 

This  is  the  largest  number  that  I  have  known  to  come  from  one 
child.  The  round-worm  is  rare  in  New  York  city  children.  I 
have  seen  but  three  cases.  In  children  who  live  in  the  country- 
it  is  of  fairly  common  occurrence. 

My  treatment  is  as  follows:  At  bedtime  I  give  from  two  to 
four  teaspoonfuls  of  castor  oil.  Early  the  following  morning,  about 
two  hours  before  breakfast,  santonin  is  given.  For  children  under 
two  years  of  age,  I  give  one  grain;  for  those  from  two  to  four 
years  of  age,  one  and  one-half  grains;  after  the  fourth  year,  two 
grains  mav  be  given.  It  is  prescribed  in  a  powder  with  an  equal 
quantitv  of  sugar  of  milk,  or  in  capsule.  If  the  passage  of  worms 
follows  its  use,  the  treatment  is  repeated  in  three  days,  and  again  in 
a  week,  if  worms  are  passed  after  the  second  treatment. 

Thread-worms. — Thread-worms  or  pin-worms  are  more  frequently 
seen  in  city  children  than  are  either  round-worms  or  tape-worms. 
They  produce  an  irritation  and  itching  about,  and  a  pricking  sen- 
sation within,  the  anus  which  is  bitterly  complained  of  after  the 
child  is  in  bed  for  the  night,  the  parasites  betng  particularly  active 
at  this  time.  If  there  is  any  doubt  as  to  their  presence,  the  patient 
should  receive  a  full  dose  of  castor  oil — at  least  two  teaspoonfuls. 
The  discharges  should  be  kept  for  inspection.  If  the  parasites 
are  present,  they  will  be  seen  in  the  form  of  pieces  resembling  white 
thread,  from  one-fourth  to  one-eighth  inch  in  length.  They  will 
usually  be  found  embedded  in  a  considerable  quantity  of  mucus. 

Treatment. — Drugs. — Santonin,  recommended  by  some  writers  as 
of  service  in  these  cases,  has  been  without  the  slightest  value  in  my 
hands.  In  fact,  the  use  of  drugs  of  any  kind  seems  to  be  of  very 
little  service.  After  the  third  year,  turpentine  in  one-drop  doses  is 
probably  the  most  valuable  internal  medication.  It  may  be  given 
in  emulsion  or  dropped  upon  sugar. 

Rectal  Injections. — Local  treatment  with  the  infusions  of  garlic  or 
quassia  must  be  our  principal  reliance  in  the  management  of  these 
oftentimes  obstinate  cases.  In  patients  in  whom  the  worms  have 
existed  for  a  considerable  time,  the  resulting  irritation  will  cause  a 
profuse  secretion  of  mucus  in  the  descending  colon  and  sigmoid. 
This  mucus  must  be  washed  out  before  any  direct  treatment  can 
be  brought  to  play  upon  the  parasite.  The  colon  is  first  irrigated 
with  a  solution  of  one  tablespoonful  of  borax  to  a  pint  of  water. 
For  this  purpose  a  No.  18  American  catheter  should  be  used,  as  in 
colon  flushings.  The  tube  should  be  introduced  for  at  least  ten 
inches.  No  attempt  is  made  to  have  the  solution  retained.  The 
child  is  encouraged  to  bear  down  and  expel  the  water  alongside  of  the 
tube.  After  the  washing  is  completed,  eight  ounces  of  the  infusion 
of  quassia  is  passed  into  the  colon.  To  facilitate  its  retention  the 
tube  is  quickly  withdrawn,  and  the  child  placed  on  his  left  side 
with  the  buttocks  elevated  on  a  pillow.  This  position,  or  at  least 
the  recumbent  position,   should  be  maintained  for    one-half    hour 


2l6  GASTRO-ENTERIC    DISEASES 

after  the  injection  is  given.  A  solution  of  the  bichlorid  of  mercury 
I  :  10,000  may  be  used  in  the  same  way.  For  ordinary  family  use, 
however,  I  consider  either  the  garlic  or  the  quassia  much  safer  and 
equally  effective.  Garlic  is  particularly  effective,  but  its  very  dis- 
agreeable odor  makes  its  use  objectionable  in  many  households,  and 
therefore  I  advise  it  only  when  other  means  fail.  After  the  worms 
and  the  evidence  of  their  presence  disappear,  the  treatment  should 
be  continued  for  a  time  on  alternate  days,  and  then  twice  a  week, 
gradually  reducing  the  frequency  of  the  irrigations  until  they  are 
no  longer  required.  Few  cases  recover  in  less  than  four  weeks, 
and  in  many  it  will  be  necessary  to  continue  the  treatment  for 
months.  I  have  never  seen  a  case,  however,  which  did  not  event- 
ually respond  to  persistent  treatment. 

The  Tape-worm. — The  tape-worm  may  produce  symptoms  of 
disturbed  intestinal  digestion,  such  as  colicky  pain  and  diarrhea. 
Usually,  however,  the  first  warning  that  the  child  is  affected  will 
be  the  passage  of  segments  of  the  worm. 

A  worm  fourteen  feet  in  length  was  passed,  after  treatment, 
by  a  little  girl  four  years  old.  There  had  never  been  a  symptom 
of  its  presence  other  than  the  passage  of  several  of  the  segments. 

The  treatment  is  as  follows:  At  bedtime  give  one-half  ounce 
of  castor  oil.  Early  the  next  morning,  two  hours  before  breakfast, 
give  one-half  dram  of  the  oleoresin  of  male-fern  (aspidium)  in  emul- 
sion or  in  capsule.  During  the  day  a  light  fluid  diet  only  is  to  be 
given,  such  as  broth,  gruels,  and  fruit-juices.  One  treatment  with  a 
good  preparation  of  the  male-fern  will  usually  bring  away  the  worm 
entire.  The  head  should  be  carefully  searched  for  with  a  magni- 
fying glass.  If  it  is  not  found,  the  treatment  should  be  repeated 
after  an  interval  of  twenty-four  hours. 

PROLAPSE  OF  THE  ANUS  AND  RECTUM 
In  anal  prolapse  there  is  an  eversion  of  the  mucous  membrane, 
a  condition  often  present  in  constipation  and  sometimes  seen  in 
diarrheal  conditions  of  the  dysenteric  type,  in  which  there  is  apt 
to  be  considerable  tenesmus  and  straining.  If  the  case  is  neglected, 
the  prolapse  occurring  repeatedly  for  many  days  in  succession  in 
cases  of  constipation,  or  several  times  a  day  in  the  acute  intestinal 
cases,  the  sphincter  gradually  becomes  weakened,  the  prolapse 
more  pronounced,  and  sooii  a  considerable  portion  of  the  involuted 
rectum  appears  with  each  defecation. 

Cases  of  simple  eversion  are  usually  relieved  by  controlling  the 
diarrhea,  or,  when  due  to  constipation,  by  supporting  the  perineum 
■  during  defecation.  This  support  is  best  furnished  by  wrapping 
a  considerable  quantity  of  absorbent  cotton  around  the  index-finger, 
which  rests  against  and  supports  the  perineum.  The  child  should  lie 
on  its  back  during  defecation.  The  troublesome  cases  are  those  due 
to  constipation  in  "runabout"  children,  where  the  prolapse  has  been 


PROLAPSE  OF  the;  ANUS  AND  RECTUM  217 

repeated  every  day  for  several  months.  Such  children  usually  show 
evidence  of  illness  other  than  the  local  conditions  and  the  consti- 
pation. They  are  usually  underfed  and  poorly  nourished.  Many 
are  rachitic  or  show  the  ear-marks  of  a  previous  rachitic  state. 

Operation  Contraindicated. — The  reduction  of  the  prolapse  can 
usually  be  readily  effected  by  pressure  on  the  protruding  mass  with  ab- 
sorbent cotton  which  has  been  dipped  in  warm  sterilized  olive  oil. 
The  only  means  of  permanently  curing  prolapse  of  the  rectum  and 
anus,  is  effectively  and  at  once  to  prevent  the  recurrence.  Operation 
bv  removing  sections  of  the  mucous  membrane,  thus  narrowing  the 
rectal  outlet,  the  use  of  the  actual  cautery  or  of  nitrate  of  silver,  is 
unnecessary  according  to  my  observation.  Oftentimes  such  opera- 
tions are  productive  of  much  harm.  They  are  unnecessary,  because 
the  case  will  get  well  with  much  simpler  means;  and  harmful  because 
of  the  pain  and  the  days  of  discomfort  which  may  follow  such  pro- 
cedures, to  say  nothing  of  the  dangers  of  infection  and  the  possibil- 
ities of  resulting  stricture  and  deformities  of  the  parts. 

Treatment. — Hygienic. — In  undertaking  a  case  of  habitual  pro- 
lapse of  the  rectum  it  is  necessary  that  the  child  be  put  in  the  most 
favorable  physical  condition.  As  these  children  are  usually  consti- 
pated, the  diet  advised  for  the  constipated  (page  171)  should  be 
used.  If  thread- worms  are  present  as  a  cause,  the  treatment  should 
be  directed  toward  their  removal.  If  the  child  is  anemic  or  rachitic, 
means  must  be  employed  to  bring  the  physical  condition  up  to  the 
highest  possible  standard. 

Postural. — When  we  have  properly  prepared  the  patient,  by 
thus  carefully  attending  to  his  general  condition,  we  are  in  a  posi- 
tion to  relieve  the  prolapse.  We  begin  as  follows:  At  bedtime 
introduce  into  the  colon  four  ounces  of  warm  sweet  oil  (page  174). 
This  will  rarely  cause  an  evacuation.  In  case  this  should  happen, 
only  one  or  two  ounces  should  be  used.  The  following  morning, 
after  the  first  meal,  the  child  is  placed  in  a  recumbent  position 
on  a  bed-pan  with  the  buttocks  elevated  to  a  plane  at  least  four 
inches  higher  than  the  child's  shoulders.  In  order  to  establish  the 
habit  of  a  daily  evacuation  at  a  proper  time,  a  glycerin  suppository, 
infant  size,  is  inserted.  If  an  evacuation  does  not  take  place 
within  a  few  minutes,  eight  ounces  of  soap- water  should  be  intro- 
duced. After  a  few  days  of  the  suggestion  afforded  by  the  prepara- 
tion, the  position  of  the  patient,  together  with  his  natural  efforts 
toward  a  movement  of  the  bowels,  will  render  artificial  stimulation 
unnecessary.  The  advantages  of  postural  treatment  are  obvious. 
By  lessening  the  abdominal  pressure,  which  is  much  greater  when 
the  child  is  in  the  upright  position,  much  less  force  is  exerted  on 
the  weakened  structures,  and  the  patient  is  in  a  position  in  which 
the  attendant,  by  suitable  perineal  support,  by  pressing  the  but- 
tocks together,  may  better  prevent  the  prolapse.  If  the  case  is 
a  severe  one,  the  recumbent  position  for  each  daily  evacuation  must 


2l8  GASTRO-ENTERIC    DISEASES 

be  continued  for  six  weeks  or  longer  before  the  defecation  is  allowed 
to  occur  with  the  child  in  the  sitting  posture.  If  later  the  prolapse 
is  repeated,  four  weeks  more  of  the  postural  treatment  must  be 
carried  out. 

Supplementary. — After  the  child  is  apparently  cured,  the  bowel 
function  must  be  carefully  watched  for  months ;  twenty-four  hours 
should  never  pass  without  a  movement.  If  a  laxative  is  necessary, 
as,  in  a  few  cases,  it  will  be,  two  or  three  teaspoonfuls  daily  of  the  milk 
of  magnesia  given  in  the  child's  milk  affords  a  satisfactory  laxative, 
as  it  produces  a  soft  stool  and  does  not  have  a  pronounced  effect 
upon  intestinal  peristalsis. 

The  child  at  first  may  not  take  kindly  to  the  postural  treatment; 
but  after  a  reasonable  amount  of  coaxing  and  bribing,  he  soon 
becomes  accustomed  to  it.  I  have  never  had  any  trouble  in  hav- 
ing the  directions  carried  out,  because  of  the  objections  of  the  child. 

ISCHIORECTAL  ABSCESS 

An  abscess  of  this  type  is  occasionally  seen  in  infant  asylums, 
babies'  hospitals,  and  in  out-patient  work.  It  is  usually  found  in 
ill-conditioned  children.  Such  an  abscess  is  generally  the  result  of 
an  infection  of  the  lymph-glands  in  the  neighborhood  of  the  rectum. 
As  a  rule,  the  abscess  is  not  deeply  situated  and  its  cure  is  easy. 

All  that  is  required  is  a  free  incision,  a  daily  washing  out  of 
the  abscess  cavity  with  a  3  percent  solution  of  hydrogen  per- 
oxid  and  packing  with  sterilized  gauze  moistened  with  a  satu- 
rated solution  of  boric  acid.  A  layer  of  gauze,  covered  with  oiled 
silk,  should  cover  the  dressing  to  protect  the  wound  from  further 
infection  from  the  fecal  discharges.  In  case  the  granulations  are 
sluggish,  as  they  may  be  in  marasmic  infants,  the  gauze  used  for 
the  packing  may  be  saturated  with  the  balsam  of  Peru. 

HEMORRHOIDS 
While  a  comparatively  rare  condition  in  children,  hemorrhoids 
are  occasionally  seen.  Constipation  and  neglect  of  cleanliness 
appear  to  have  been  the  cause  in  most  of  my  cases.  The  treat- 
ment is  to  relieve  the  constipation  and  carefully  cleanse  the  anus 
with  hot  water  and  soap  after  each  movement  of  the  bowels,  after 
which  an  ointment  composed  of  the  following  ingredients  is  applied : 

I^.     Acidi  tannici gr.  x 

Pulveris  camphorae gr.  v 

Ichthyoli 5  iss 

Unguenti  zinci  oxidi q.  s.  ad   oj 

The  ointment,  in  addition  to  its  use  after  an  evacuation  of  the  bowels, 
should  be  generously  applied  to  the  anus,  night  and  morning,  after 
washing. 


RECTAL  POLYPUS.   INCONTINENCE  OF  FECES        219 

RECTAL  POLYPUS 

According  to  my  observation,  rectal  polypus  is  a  rare  condition. 
My  cases  have  been  three  in  number  and  in  children  between  the 
ages  of  five  and  seven.  In  all  these  cases  the  polypus  was  discovered 
by  the  mother  after  the  child's  evacuation  of  the  bowels.  It  may 
easily  be  recognized  as  an  oval,  deeply  congested  tumor  protruding 
from  the  anal  orifice. 

In  these  children  there  had  been  slight  hemorrhage  from  time 
to  time  with  the  evacuations,  the  feces  being  streaked  with  blood. 
The  polypi,  in  these  cases,  were  easy  of  diagnosis,  as  they  were 
situated  low  down  on  the  rectal  wall,  each  with  a  rather  narrow 
pedicle.     They  were  readily  ligated  and  removed. 

Repeated  bleeding  from  the  rectum  in  apparent  health  should 
always  suggest  the  possibility  of  a  polypoid  growth.  Hemorrhoids 
also  are  very  rare  in  young  children.  Pain  and  tenesmus  are  early 
signs  of  fissure,  so  that  bleeding  from  such  a  source  may  readily 
be  accounted  for. 

INCONTINENCE  OF  FECES 

Incontinence  of  feces  is  a  normal  condition  during  infancy,  control 
being  established  without  training  during  the  second  year  or  earlier. 
In  well-trained  infants  I  have  seen  the  bowel  function  under  perfect 
control  at  the  third  month.  This  is  unusual,  however.  Still,  with  a  very 
little  teaching  it  may  be  accomplished  at  the  sixth  month.  Incontin- 
ence of  feces  in  older  children  occurs  during  acute  inflammatory  condi- 
tions, particularly  when  the  colon  is  the  seat  of  the  lesion.  It  may 
also  be  present  in  asthenic  states,  as  in  grave  pneumonia,  in  tvphoid 
fever,  and  in  severer  types  of  the  exanthemata,  and  it  may  occur 
accidentally  as  the  result  of  a  fright,  shock,  or  of  severe  straining. 

Incontinence  of  feces,  as  a  condition  independent  of  the  age 
element  and  illness,  is  of  exceedingly  unusual  occurrence.  I  have 
seen  but  two  cases — both  boys,  one  four  and  the  other  seven  vears 
of  age.  In  both,  the  condition  had  persisted  for  months.  The 
desire  for  an  evacuation  in  these  cases  came  with  great  urgency 
and  was  uncontrollable.  There  was  no  diarrhea  or  evidence  of 
any  intestinal  lesion.  One  was  a  dispensary  patient,  the  other 
was  seen  in  private.  Both  were  wretchedly  nourished  children, 
both  had  been  badly  managed  and  badly  fed.  Incontinence  rarely 
occurred  at  night.  During  the  day,  however,  it  sometimes  took  place 
two  and  three  times.     The  patients  were  on  a  general  mixed  diet. 

The  treatment  was  the  removal  of  green  vegetables  and  fruit  from 
the  diet,  allowing  only  a  small  amount  of  starches,  such  as  bread, 
potato,  and  cereals;  eggs,  meat,  fish,  skimmed  milk,  junket,  custard, 
etc.,  were  given  freely.  Medically  they  were  given  fifteen  drops  of  the 
tincture  of  the  muriate  of  iron  in  glycerin  and  water  every  four  hours, 
with  one  grain  of  Dover's  powder  and  twenty  grains  of  subnitrate  of 
bismuth  (Squibb)  three  times  daily.  Both  cases  recovered  com- 
pletely, one  in  three  weeks,  the  other  in  five. 


THE  MOUTH,  THROAT,  AND  NOSE 

STOMATITIS 

The  term  stomatitis  is  applied  to  an  inflammation  of  the  mucous 
membrane  of  the  mouth.  Three  types  are  usually  described  by 
pediatric  authors — the  catarrhal,  the  aphthous,  and  the  ulcerative. 
This  division  is  perhaps  more  the  result  of  the  habit  of  copying 
from  former  writers  than  from  clinical  observation.  Among  sev- 
eral thousand  out-patient,  institution,  and  hospital  patients,  it 
has  been  my  privilege  to  treat  many  cases  of  stomatitis. 

There  are  many  cases  of  catarrhal  stomatitis  which  under  treat- 
ment go  no  further;  other  cases,  with  or  without  treatment,  go 
on  to  the  development  of  aphthae,  or  to  an  ulcerative  condition, 
or  both  conditions  may  be  combined.  Many  cases,  when  they 
appear  for  treatment,  have  the  so-called  aphthous  spots  already 
developed,  but  the  condition  described  as  "catarrhal  stomatitis  " 
is  present  also.  Other  cases  when  they  come  to  us  show  marked 
ulceration,  but  never  without  catarrhal  symptoms. 

The  first  symptom  of  a  stomatitis  is  a  superficial  catarrhal  inflam- 
mation of  the  mucous  membrane  of  the  mouth.  There  is  a  redness 
and  injection  of  the  gums.  If  "aphthae"  develop,  small  grayish 
plaques  appear  on  the  mucous  surface  of  any  portion  of  the  buccal 
cavity.  In  mild  cases  there  may  be  but  three  or  four  areas.  In 
a  case  of  moderate  severity  the  mucous  membrane  of  the  gums, 
the  hard  and  soft  palate,  and  the  inner  side  of  the  cheeks  will  be 
studded  with  ulcerated  grayish-white  areas,  in  size  from  a  pinhead 
to  a  split  pea.  Occasionally  the  areas  coalesce,  forming  larger 
plaques  of  a  serpiginous  type. 

tjlceration  ordinarily  does  not  appear  until  after  the  catarrhal  con- 
dition has  been  present  for  at  least  three  or  four  days.  It  will  first  be 
noticed  as  a  faint  yellow  line  at  the  margin  of  the  gum  where  it  joins 
the  teeth.  This  is  the  commencement  of  what  Virchow  describes  as 
"necrobiosis."  Ulceration  never  occurs  unless  teeth  are  present.  I 
have  never  known  a  case  to  go  on  to  ulceration  in  a  baby  fed  entirely 
at  the  breast.  Whether  the  case  remains  simply  catarrhal,  or  whether 
aphthae  or  ulceration  or  both  result,  certain  symptoms  are  common  to 
all.  There  is  a  marked  increase  in  the  flow  of  saliva,  which,  in  some 
cases,  may  be  said  to  stream  from  the  mouth,  running  down  over 
the  chin  and  soiling  the  clothes.  On  account  of  its  acid  properties 
it  causes  an  irritation  of  the  skin,  producing  an  eczema.  The  mouth 
is  hot  and  painful.     Fever  is  present  in  a  slight  degree,  both  when 


STOMATITIS  221 

the  condition  is  simply  catarrhal  and  when  aphthae  are  present. 
There  is  but  little  prostration  and  the  child  appears  but  slightly 
indisposed.  In  cases  which  go  on  to  ulceration,  the  fever  may  be 
very  high.  I  have  frequently  seen  it  at  104°  F.  or  over.  In  one 
case  it  reached  107°  F.  No  cause  except  the  ulcerative  stomatitis 
could  be  found  for  the  fever.  Under  properly  directed  treatment, 
the  child  recovered  in  a  few  days. 

On  account  of  the  pain  occasioned  by  drawing  on  the  nipple, 
nutrition  may  be  considerably  interfered  with  in  these  cases.  The 
child  takes  the  breast  or  bottle  greedily,  draws  a  few  times,  stops 
and  begins  to  cry.  If  urged  to  try  again,  the  process  is  repeated. 
The  pain  appears  to  be  particularly  severe  when  aphthae  are  present. 
The  advent  of  ulceration  will  be  indicated  by  a  change  in  the  breath, 
which  becomes  disgustingly  foul.  The  gums  are  thick,  spongy, 
and  bleed  easily,  and  in  some  cases  overlap  the  teeth  very  early 
in  the  ulcerative  stage.  If  a  case  has  been  neglected  or  improperly 
treated,  which  was  the  history  of  not  a  few  of  my  dispensary 
patients,  the  ulceration  was  often  so  extensive  that  the  teeth  be- 
came loose  as  a  result  of  the  destruction  of  the  gums,  and  their 
removal  was  necessary.  Strong,  vigorous  children  are  as  suscep- 
tible to  the  disease  as  are  the  rachitic,  the  badly  fed,  or  the  generally 
delicate. 

The  cause  of  the  disease  is  unquestionably  an  infection,  and 
there  is  no  doubt  that  it  is  contagious.  As  to  the  nature  of  the 
infection,  positively  nothing  is  known.  The  combined  action  of 
several  varieties  of  microorganisms  is  the  most  plausible  explanation, 
I  have  known  it  to  go  through  an  entire  family  of  several  children. 
Authors  are  prone  to  attribute  the  trouble  primarily  to  mechanical 
irritation,  such  as  careless  manipulation  during  the  mouth  toilet; 
but  the  majority  of  my  cases  when  they  applied  for  treatment  had 
never  been  accustomed  to  mouth  toilets  of  any  kind.  The  giving 
of  overheated  food  is  supposed  by  some  to  be  a  causative  agent. 
If  this  w^ere  the  case,  75  percent  of  the  infants  among  the  poorer 
classes  would  never  be  free  from  the  disease.  The  food  of  bottle- 
fed  children  unless  carefully  watched  is  almost  invariably  given 
too  hot.  The  disease,  however,  is  not  limited  to  dispensary  patients. 
I  have  seen  many  cases  among  the  well-to-do.  Where  gross  un- 
cleanliness  is  the  family  habit,  the  number  of  cases  of  stomatitis 
will,  for  obvious  reasons,  be  greater;  there  are  more  bacteria  to 
carry  infection.  Children  whose  mouths  are  carefully  cleaned  after 
each  feeding,  do  not  develop  stomatitis.  To  teach  that  a  child's 
mouth  should  not  be  washed  because  an  indifferent  doctor  may 
fail  to  instruct  the  mother  or  nurse  as  to  how  it  should  be  done  is 
rank  heresy.  When  errors  of  the  mother  or  nurse  occur  in  per- 
forming the  various  offices  for  the  child,  it  is  my  observation  that, 
nine  times  out  of  ten,  it  is  due  to  the  lack  of  teaching  by  the  careless 


222  THE  MOUTH,  THROAT,  AND  NOSE 

physician.     The  mouth  may  be  very  effectually  cleansed  without 
injuring  the  mucous  membrane  in  the  slightest  degree. 

Treatment. — Mouth-washing. — When  the  stomatitis  is  catarrhal 
or  aphthous,  preventive  treatment — the  washing  of  the  mouth  after 
each  feeding  with  a  saturated  solution  of  boric  acid  in  boiled  water 
• — is  also  curative.  A  baby's  mouth  should  be  washed  as  follows: 
The  child  is  placed  on  its  side  or  on  its  stomach,  the  index-finger 
of  the  mother  or  nurse  being  thoroughly  wrapped  in  absorbent 
cotton.  The  finger  is  then  dipped  into  the  solution,  and  without 
expressing  the  fluid  it  is  placed  in  the  child's  mouth.  By  gentle 
pressure  upon  the  gums  and  cheeks  a  sufficient  amount  of  the  fluid 
will  be  expressed  to  run  out  of  the  mouth  and  effectually  cleanse 
it.  The  washing  is  assisted  by  the  opposition  oft'ered  by  the  child 
to  the  manipulation  of  the  tongue,  cheeks,  and  jaws. 

Drugs. — Internal  medication  is  of  no  value  so  far  as  concerns  the 
stomatitis,  except  indirectly.  If  there  is  a  disordered  digestive  tract, 
it  should  receive  attention  by  diet  and  saline  laxatives.  Calomel 
should  not  be  given.  Whether  the  condition  was  catarrhal  or 
aphthous,  I  have  never  found  it  necessary  to  use  other  means  than 
the  free  mouth-washing.  Astringents  and  caustics  have  never 
been  necessary.  The  cases  usually  recover  in  from  four  to  seven 
days,  under  strict  attention  to  cleanliness  as  regards  the  feeding 
apparatus  in  the  bottle-fed,  or  the  mother's  nipple  in  the  nursling, 
together  with  the  free  use  of  the  boric  acid  solution  as  a  mouth-wash. 

Feeding. — The  food  problem  is  oftentimes  a  difficult  one  to  deal 
with,  particularly  in  nurslings,  on  account  of  the  pain  caused  by  draw- 
ing on  the  nippie,  the  child  refusing  absolutely  to  nurse.  In  some 
cases  it  may  be  necessary  to  draw  the  milk  with  a  breast-pump, 
and  for  a  day  or  two  feed  the  baby  with  a  spoon.  In  the  bottle- 
fed,  spoon-feeding  may  also  be  resorted  to.  The  child  will  take 
the  nourishment  much  better  if  it  is  given  cool.  Small  pieces  of 
ice  and  teaspoonful  doses  of  cold  water  are  taken  eagerly. 

Treatment  after  Ulceration. — With  the  development  of  ulcera- 
tion a  change  in  the  management  is  necessary,  both  as  regards  a 
mouth-wash  and  the  necessity  for  internal  medication.  Among  the 
local  measures  hydrogen  peroxid  as  a  mouth-wash,  one  part  of  a  3 
percent  solution  in  two  parts  of  water,  used  after  each  feeding,  has 
given  the  best  results.  Such  means,  however,  are  rarely  necessary 
if  the  case  is  seen  early.  I  never  employ  other  than  the  usual 
means  of  cleanliness — the  boric  acid  solution — except  in  cases  that 
show  a  considerable  destruction  of  tissue. 

Chlorate  of  Potash. — In  the  internal  administration  of  chlorate  of 
potash  we  have  what  is  practically  a  specific  in  this  disease.  Its  ad- 
ministration should  be  commenced  as  soon  as  the  condition  is  recog- 
nized. I  usually  prescribe  it  in  the  syrup  of  raspberry,  using  one  part 
of  the  syrup  to  two  parts  of  water.     For  a  child  under  eighteen  months 


SPRUE;  thrush;  mycotic  stomatitis  223 

of  age  I  order  two  grains  at  intervals  of  two  or  three  hours,  not 
more  than  ten  grains  in  twenty-four  hours.  For  a  child  from  eigh- 
teen months  to  three  years  of  age,  two  or  three  grains  at  the  same 
intervals,  not  more  than  fifteen  grains  in  twenty-four  hours.  With 
the  above  dosage  it  will  be  necessary,  in  the  average  case,  to  con- 
tinue the  drug  from  three  to  five  days.  Very  often,  after  the 
improvement  is  well  marked,  I  reduce  the  dose  one-half  and  con- 
tinue it  for  three  or  four  days  longer. 

Much  has  been  written  as  to  the  danger  of  the  internal  use  of 
chlorate  of  potash  in  children,  particularly  in  relation  to  its  effects 
upon  the  kidneys.  If  the  use  of  the  drug  in  suitable  doses  were 
of  special  danger  in  this  respect,  the  free  use  of  the  chlorate  of  potash 
and  iron  mixture,  so  extensively  prescribed  in  diphtheria  in  the 
pre-antitoxin  period,  would  have  been  universally  condemned. 
I  have  never  seen  any  unpleasant  effects  from  its  use  when  given 
in  doses  of  from  two  to  twenty  grains  daily,  and  I  have  used  it  in 
many  hundreds  of  cases  of  acute  inflammatory  conditions  of  the 
throat  and  mouth. 

SPRUE;   THRUSH;   MYCOTIC  STOMATITIS 

Thrush  consists  of  a  parasitic  growth  which  appears  on  the 
mucous  membrane  of  the  mouth  in  young  infants.  Plant,  in  his 
classification  of  diseases  of  the  mouth,  calls  it  a  fungous  growth, 
monilia  Candida.  The  disease  makes  its  appearance  in  the  form 
of  small  white  masses  about  the  size  of  a  pinhead.  The  tongue 
and  the  inner  side  of  the  cheeks  are  favorite  sites  for  the  growth, 
although  in  severe  cases  the  entire  buccal  cavity  may  be  studded 
with  it,  causing  it  to  look  as  though  finely  curdled  milk  had  been 
scattered  over  the  surface.  The  growth  is  firmly  adherent,  and  if 
removed  forcibly,  slight  bleeding  results.  It  is  invariably  associated 
with  uncleanliness,  and  occurs,  as  a  rule,  in  weakly  and  marasmic 
nurslings  and  in  the  bottle-fed,  more  frequently  in  the  latter.  It 
is  rarely  seen  after  the  sixth  month. 

In  an  infant  with  sprue,  there  is  evidence  of  much  pain  and  dis- 
comfort while  nursing  or  while  feeding  from  a  bottle.  The  disease 
is  not  contagious.  The  average  case  may  easily  be  cured  in  a  week, 
if  the  directions  for  the  treatment  are  carefully  carried  out.  Active 
gastro-enteric  disturbances,  such  as  vomiting  and  diarrhea,  may  be 
associated  with  sprue,  but  it  is  not  the  rule.  Time  and  again  I 
have  seen  cases  of  sprue  in  which  there  were  absolutelv  no  other 
signs  of  the  disease  aside  from  the  characteristic  mouth  lesions 
and  the  refusal  of  food. 

If  the  means  of  prophylaxis,  which  will  be  suggested,  are  used 
as  the  daily  routine,  the  disease  will  never  appear. 

Treatment. — If  breast-fed,  the  mother's  nipples  must  be  washed 
with  a  saturated  solution  of  boric  acid  and  moistened  with  alcohol, 


224  'f^^    MOUTH,    THROAT,    AND   NOSE 

diluted  one-half,  which  is  allowed  to  evaporate  before  each  nursing. 
If  bottle-fed,  the  nipple  and  bottle  should  be  boiled  after  each  nursing, 
the  nipples  turned  inside  out  and  scrubbed  with  borax  water — one 
ounce  of  borax  to  a  pint  of  water.  Whether  breast-fed  or  bottle- 
fed,  the  mouth  should  be  washed  wath  a  saturated  solution  of  boric 
acid  after  each  nursing.  For  this  purpose  a  generous  amount  of 
absorbent  cotton  is  loosely  wrapped  around  the  clean  index-finger 
of  the  mother  or  nurse.  This  is  placed  in  the  cold  solution,  and 
without  pressing  out  the  water  the  finger  is  introduced  into  the 
child's  mouth,  and,  in  cases  of  sprue,  brought  gently  in  contact 
with  the  diseased  parts,  first  with  one  side  and  then  with  the  other,- 
being  pressed  upon  the  tongue  and  under  the  tongue.  It  is  well 
to  have  the  child  rest  on  its  side  or  stomach  so  that  the  fluid  which 
is  pressed  out  by  the  manipulation  of  the  cotton  against  the  cheeks 
and  javv^s  can  readilv  escape  from  the  mouth.  The  washing,  which 
really  amounts  to  an  irrigation,  can  be  done  in  a  few  seconds,  with- 
out the  slightest  danger  of  abrading  the  epithelium.  In  obstinate 
cases,  the  parts  may  be  penciled  once  a  day  with  a  i  percent  solution 
of  formalin,  in  addition  to  the  other  treatment. 

Internal  medication  is  of  no  value  in  sprue  except  in  correcting 
any  intestinal  derangement  that  may  exist,  with  a  view  to  improv- 
ing the  general  condition.  If  the  bottle  or  breast  is  refused,  spoon- 
feeding for  a  few  days  may  be  necessary,  and  will  hasten  a  cure. 
If  the  child  is  nursed,  the  mother's  milk  maybe  drawn  w^ith  a  breast- 
pump  (see  page  79)  or  pressed  out  with  the  fingers  and  fed  to 
the  child.  The  domestic  remedy,  honey  and  borax,  should  not  be 
used  in  any  of  the  inflammatory  diseases  of  the  mouth  in  children. 

CANCRUM  ORIS;  NOMA 
This  disease  is  unquestionably  the  work  of  a  specific  microbe, 
the  nature  of  which  is  unknown.  The  site  of  the  disease  is  usually 
the  inner  side  of  the  cheek ;  either  one  or  both  sides  may  be  involved. 
The  gangrenous  process  usually  begins  as  a  small,  inflamed,  in- 
filtrated area  in  the  mucous  membrane  opposite  the  teeth.  Destruc- 
tion of  tissue,  distinctly  localized,  follows  and  extends  with  great 
rapidity,  the  tissue  sloughing  away  in  masses.  The  parts  for 
some  distance  around  the  ulcer  are  hard,  infiltrated,  and  discolored, 
presenting  an  inflamed  edematous  look.  After  two  or  three  days 
a  discolored,  ecchymosis-hke  area  w^fl  be  noticed  on  the  outer  side 
of  the  cheek,  corresponding  in  location  to  the  gangrenous  process 
within.  At  this  point  the  ulcer  soon  perforates.  The  destruction 
of  tissue  continues  quite  symmetrically  around  the  ulcer  until  the 
whole  cheek  is  destroyed.  The  gangrenous  process  not  infrequently 
involves  the  bony  structure,  causing  necrosis  of  the  jaw  with  a 
loosening  and  failing  out  of  the  teeth.  A  symptom  which  will 
never  fail,  and  can  never  be  forgotten  by  one  who  has  seen   even 


BEDNAR  S    APHTH/E  225 

one  of  these  cases,  is  the  almost  unbearable  stench  which  emanates 
from  the  patient.  When  the  hands  or  the  fingers  of  the  physician 
or  nurse  come  in  contact  with  the  gangrenous  slough,  it  is  well- 
nigh  impossible  to  remove  or  neutraUze  the  disgusting  odor.  The 
disease  usually  occurs  in  weakly,  marantic  children,  who  generally 
die  from  exhaustion  and  sepsis  in  ten  days  or  two  weeks  from  the 
onset  of  the  disease. 

Treatment. — The  treatment  pursued  has  been  the  use  of  free  cau- 
terization with  nitric  acid,  chemically  pure,  and  disinfectant  wet 
dressings  of  bichlorid  i  :  2000 ;  a  saturated  solution  of  boric  acid ;  or 
equal  parts  of  alcohol  and  water.  The  latter  is  apparently  more  effec- 
tive in  staying  the  progress  of  the  disease  than  is  either  the  bichlorid 
or  the  boric  acid  solution.  On  account  of  the  rapid  evaporation, 
it  should  be  applied  on  two  or  three  layers  of  hnt  and  covered  with 
rubber  tissue.  Even  then  it  requires  very  frequent  renewals.  Hy- 
drogen peroxid  may  be  used  to  cleanse  the  ulcer,  both  before  and 
after  perforation.  Hemorrhage  is  rarely  a  complication.  The 
disease  is  usually  fatal,  even  under  the  best  management. 

BEDNAR'S  APHTHA 

What  is  known  as  "Bednar's  aphthge  "  is  not  an  aphtha,  but 
an  ulcer.  Among  the  many  cases  I  have  seen,  not  one  was  in  a  child 
over  four  months  of  age.  It  is  most  often  seen  in  poorly  nourished 
children. 

The  disease,  when  well  developed,  consists  of  a  "  punched-out  " 
appearing  ulcer  which  is  seen  on  the  hard  palate,  usually,  but  not 
invariably,  at  its  posterior  portion.  I  have  in  but  one  case  seen  two 
ulcers  present  at  the  same  time — one  on  either  side  of  the  mesial  line. 
As  a  rule,  the  process  is  limited  to  one  side  of  the  hard  palate.  All 
the  cases  seen  by  me  were  in  bottle-fed  children,  usually  those  fed 
with  a  long  nipple,  or  those  using  a  "pacifier,"  a  cork-plugged 
nipple,  or  some  other  sucking  apparatus.  The  cases  always 
appeared  to  be  due  to  a  prolonged  mechanical  irritation.  The 
ulcer  caused  no  other  symptoms  than  interference  with  feeding. 
The  patient  is  usually  brought  for  treatment  for  this  reason. 
The  child  appears  lively,  but  refuses  the  bottle  after  an  attempt 
at  nursing.  The  mother  examines  the  child's  mouth,  discovers  the 
ulceration,  and  brings  the  child  with  a  story  of  an  inabilitv  to 
take  the  bottle.  An  examination  of  the  mouth  shows  the  presence 
of  the  characteristic  ulcer. 

Treatment. — As  short  a  nipple  as  is  practicable  should  be  brought 
into  use,  or,  what  is  better,  the  child  may  be  fed  with  a  spoon  for  a  few 
days,  for  as  long  as  the  local  irritation  is  continued  improvement  is 
impossible.  The  local  treatment  consists  in  washing  the  mouth  with 
a  saturated  solution  of  boric  acid  (see  page  224)  after  each  feeding, 
and  the  application  to  the  ulcer  once  daily  of  a  50  percent  solution 


226  THE    MOUTH,    THROAT,    AND   NOSE 

of  nitrate  of  silver.  This  is  best  accomplished  by  means  of  a  tooth- 
pick, one  end  of  which  is  wrapped  with  absorbent  cotton,  the  child 
resting  on  its  back  on  the  nurse's  lap  or  on  a  table.  The  nurse 
holds  the  child's  arms  to  its  side  while  the  physician,  with  his  left 
hand,  separates  the  jaws  with  a  spoon  or  a  tongue-depressor,  and 
with  his  right,  the  child  being  thus  under  perfect  control,  the  appli- 
cation can  easily  be  made.  The  ulcer  should  thus  be  treated  daily 
for  four  or  five  days  until  it  has  healed. 

FISSURES  OF  THE  LIPS 
Deep  cracks  and  fissures  in  the  lips  are  of  quite  frequent  oc- 
currence among  out-patient  children.  Usually  the  lower  lip  is 
involved,  and  in  many  of  the  cases  there  will  be  but  one  deep  fissure 
and  that  about  the  middle  of  the  lower  lip.  Marasmic,  ill-condi- 
tioned children  are  the  most  frequent  sufferers.  The  fissures  bleed 
easily  and  occasion  considerable  pain  while  nursing.  As  a  result, 
less  food  is  taken  than  the  child  requires.  If  the  fissure  is  a  deep 
one,  it  will  be  well  to  apply  a  50  percent  solution  of  nitrate  of  silver 
at  the  commencement  of  the  treatment.  This  is  to  be  followed 
by  frequent  applications — three  or  four  times  daily — of  a  25  per- 
cent solution  of  ichthyol.  Healing  is  usually  prompt,  requiring 
but  a  few  days.  If  the  mucous  membrane  of  the  lip  generally  is 
dry  and  fissured,  as  in  cases  of  prolonged  illness  with  fever,  the  fre- 
quent use  of  a  5  percent  boric  acid  ointment,  made  with  cold-cream 
as  a  base,  will  be  of  material  assistance  in  controlling  the  condition. 

ULCERATIONS  AND  FISSURES  AT  THE  ANGLE  OF  THE  MOUTH 
Ulcerations  and  fissures  at  the  angle  of  the  mouth  are  by  no 
means  uncommon  in  delicate  and  marasmic  infants.  While  ulcera- 
tion in  this  location  is  one  of  the  manifestations  of  congenital 
syphilis,  such  ulcers  are  not  necessarily  syphilitic.  The  condition, 
however,  is  of  sufficient  importance  to  require  treatment,  because 
the  affection  is  so  painful  as  to  prevent  the  taking  of  adequate 
nourishment.  Painting  the  fissure  with  a  25  percent  solution  of 
ichthyol  every  three  hours  during  the  day  will  insure  the  prompt 
healing  of  the  fissures. 

ULCER  OF  THE  FRENUH  OF  THE  TONGUE 
An  ulceration  of  the  frenum  of  the  tongue,  "the  tongue  bridle," 
is  rarely  seen  in  well  children.  It  is  rounded,  grayish  in  appearance, 
with  a  slightly  raised  border.  It  usually  occurs  in  infants  who 
are  suffering  from  whooping-cough,  bronchitis,  or  bronchopneu- 
monia. It  is  never  seen  except  in  children  who  have  the  lower 
incisors  well  through,  the  ulceration  being  due  to  contact  of  the 
frenum  with  the  sharp  teeth  during  the  protrusion  of  the  tongue 
in  coughing.     The  ulceration  may  cause  some  difficulty  in  nursing; 


GEOGRAPHIC   TONGUE.       TONGUE-TIE  227 

it  may  be  necessary  to  feed  the  child  with  a  spoon  for  a  day  or  two ; 
the  condition  is,  however,  rarely  of  a  serious  nature. 

The  presence  of  the  ulcer  is  usually  discovered  by  the  mother 
while  attending  to  the  mouth  toilet.  The  application  of  a  50  per- 
cent solution  of  the  nitrate  of  silver  and  the  use  of  a  saturated 
solution  of  boric  acid  as  a  mouth- wash  after  each  feeding  will  quickly 
relieve  the  condition. 

GEOGRAPHIC  TONGUE 

The  condition  known  as  a  "geographic  tongue"  consists  of 
smooth,  distinct,  reddish  patches  on  the  tongue's  surface,  the  areas 
being  surrounded  by  a  light  grayish,  narrow,  raised  border.  T^e 
smooth  surfaces  comprising  the  involved  areas  are  devoid  of  epi- 
thelium; the  borders  are  composed  of  hypertrophied  papillse  which 
take  on  a  grayish  color,  making  a  distinct  framework  for  the  reddish 
areas,  which  are  almost  always  crescentic  in  shape.  This  peculiar 
marking  has  given  rise  to  the  term  "ringworm  of  the  tongue." 
Geographic  tongue  is  seen  most  frequently  in  children  under  three 
years  of  age,  and  occurs  as  often  among  the  strong  and  vigorous 
as  among  the  delicate  and  weakly.  The  condition  is  usually  dis- 
covered by  the  mother,  who,  with  much  agitation,  brings  the  child 
to  the  physician.  It  does  not  appear  to  be  due  to  and  is  usually  not 
associated  with  any  disturbance  of  the  gastro-enteric  tract.  The 
portion  of  the  tongue  which  is  not  involved  appears  perfectly  normal. 

Treatment  of  geographic  tongue  is  unnecessary,  as  it  causes 
no  symptoms  and  apparently  is  independent  of  any  disease.  It 
is  my  custom  to  assure  mothers  that  the  condition  is  of  no  con- 
sequence. It  usually  disappears  in  a  few  months.  I  have  known 
a  case  to  last  for  a  year. 

TONGUE-TIE 

Tongue-tie  is  a  condition  caused  by  the  extension  of  the  frenum 
forward,  nearly  if  not  quite  to  the  tip  of  the  tongue.  It  interferes 
somewhat  with  nursing  if  the  milk  is  hard  to  draw,  and  interferes 
generally  with  the  free  action  of  the  tongue. 

The  treatment  consists  in  dividing  the  frenum  with  curved 
scissors.  The  child  is  wrapped  in  a  large  towel  binding  its  arms 
to  its  sides.  It  is  placed  on  its  back  on  the  nurse's  lap  or  on  a 
table.  It  is  best  controlled  when  supported  by  the  nurse  with  its 
head  between  the  physician's  knees.  The  head  can  thus  be  steadied, 
leaving  both  hands  free  for  the  operation.  A  grooved  director, 
while  not  necessary,  makes  the  operation  safe  and  easy.  The  frenum 
is  fixed  in  the  slit  in  the  broad  end  of  the  director  which  rests  against 
the  tongue.  This  raises  the  tongue  and  puts  the  frenum  on  a  ten- 
sion, and  the  division  with  the  curved  scissors  is  a  simple  matter. 
Bleeding  is  usually  so  slight  that  it  need  not  be  considered. 


DISEASES  OF  THE  RESPIRATORY  TRACT 
TAKING  COLD 

By  "taking  cold"  we  understand  that  through  the  influence 
of  cold  there  is  produced  upon  some  portion  of  the  skin  an  impres- 
sion similar  to  that  of  shock.  This  impression  affects  the  entire 
body  and  manifests  itself  most  frequently  in  the  form  of  a  conges- 
tion of  the  mucous  membrane  of  the  respiratory  tract,  between 
which  and  the  skin  there  seems  to  be  an  intimate  connection.  Micro- 
organisms play  an  important  role  in  the  process.  They  are  found 
in  large  numbers  on  the  diseased  mucous  surfaces.  The  changes 
in  the  mucous  membrane  resulting  from  exposure  prepare  it  for 
their  growth  and  development.  "Taking  cold"  means  previous 
exposure,  and  what  will  constitute  a  sufhcient  degree  of  exposure 
in  one  child  may  produce  no  effect  in  another.  According  to  my 
observation  the  most  frequent  cause  of  colds  in  infancy  is  the 
effect  of  cold  air  on  a  moist  skin.  The  child  that  perspires  readily, 
or  the  child  that  is  made  to  perspire  by  unsuitable  clothing,  suffers 
most  in  this  respect,  during  the  cold  season. 

I  look  upon  inadequate  head-covering  as  a  most  frequent  cause 
of  diseases  of  the  respiratory  tract  in  the  young.  Usually  in  the 
countrv  during  cold  weather,  an  infant  is  dressed  for  the  daily  outing 
in  a  warm  room  with  the  temperature  ranging  from  70°  to  80°  F. 
He  is  wrapped  in  ample  coats,  blankets,  and  leggings.  The  child 
is  active,  throws  his  legs  and  arms  about,  and  the  dressing  thus 
far  having  consumed  considerable  time,  he  perspires  freely,  but 
still  the  dressing  is  not  completed.  On  the  head  is  placed  one 
of  the  more  or  less  artistically  decorated  airy  creations  which  are 
sold  in  the  shops  as  children's  caps.  They  furnish  httle  protection 
for  the  many  square  inches  of  the  almost  bald  little  head.  The  child 
is  taken  out  of  doors  while  the  wind  is  blowing  and  the  result  is  a 
cold,  and  how  it  came  about  is  never  understood!  He  was  supposed 
to  be  dressed  ideally  for  cold  weather.  The  notion  is  common, 
and  to  a  certain  extent  proper,  that  a  child's  head  should  be  kept 
cool.  This  theory,  however,  gives  rise  to  carelessness  as  to  the 
head-dress.  During  the  colder  months,  as  an  extra  protection,  I 
advise  mothers  to  make  a  skull-cap  of  thin  flannel,  for  the  child  to 
wear  under  the  regular  outing  cap. 

Allowing  a  child  to  sit  on  the  floor  during  the  winter  months 
is  probably  the  next  most  frequent  cause  of  his  taking  cold.  Kick- 
ing off  the  bedclothes  at  night  is  another  frequent  cause.     Taking 


ACUTE   RHINITIS  229 

the  child  from  a  warm  room  through  a  cold  hall  is  not  without 
danger.  Holding  the  child  for  a  few  moments  by  an  open  window 
during  the  cold  weather  is  often  followed  by  croup,  bronchitis, 
or  pneumonia.  The  uneven  temperature  of  the  living-rooms  and 
sleeping-rooms  in  many  of  our  apartment  homes  is  a  very  common 
cause  of  cold.  Frequently  during  the  day  the  temperature  will 
be  between  75°  and  80°  F.,  but  at  night,  when  the  fires  are  banked, 
it  falls  to  55°  or  60°  F.  or  lower.  The  child  went  to  bed  perspiring, 
kicked  off  the  bedclothes,  the  temperature  in  the  room  fell,  the 
body  became  chilled,  and  the  child  took  cold.  The  temperature 
of  the  living-room  should  range  from  70°  to  72°  F.,  the  sleeping- 
room  from  66°  to  68°  F.  Of  course,  it  will  be  impossible  to  keep 
the  temperature  at  all  times  at  these  figures,  but  the  closer  we 
approximate  to  them,  the  safer  the  child  will  be.  In  many  instances, 
colds  in  infants  are  attributed  to  the  bath.  Among  dispensary 
mothers  this  is  often  considered  a  cause  of  cold.  I  have  never 
known  a  cold  to  be  due  to  a  bath,  although,  of  course,  when  care- 
lessly given,  such  a  thing  is  possible. 

Among  rachitic  and  rheumatic  children  there  is  a  marked  pre- 
disposition to  catarrhal  affections;  they  acquire  laryngitis  and 
bronchitis  upon  very  slight  provocation.  Adults  and  "runabout  " 
children  with  coughs  and  colds  should  not  come  in  contact  with 
infants.  There  is  undoubtedly  an  element  of  contagion  in  such 
cases.  It  is  a  very  bad  practice  to  have  a  "family  pocket-handker- 
chief," The  youngest  infant  is  entitled  to  a  handkerchief  inde- 
pendent of  the  other  children,  and  one  handkerchief  should  never 
do  service  for  more  than  one  individual.  Children  should  not  be 
allowed  to  sit  on  the  floor  during  the  winter.  They  can  have  their 
playthings  on  the  bed,  on  the  sofa,  or,  for  those  under  one  year, 
in  a  clothes-basket  which  may  be  raised  on  two  thick  pieces  of  wood 
or  a  couple  of  books.  There  is  always  a  draft  near  the  floor.  The 
"pen"  referred  to  on  page  37  is  the  best  scheme  that  I  know  of 
for  keeping  children  from  the  floor. 

The  room  in  which  the  child  is  dressed  for  an  outing  should  not 
be  above  70°  F.,  better  below  it.  Securely  pinning  bed-blankets 
to  the  mattress,  or  preferably  a  combination  suit  with  "feet,"  will 
do  much  to  prevent  taking  cold  at  night. 

ACUTE  RHINITIS  (CORYZA;  SNUFFLES?  COLD  IN  THE  HEAD) 
Acute  rhinitis  is  a  very  common  ailment  throughout  childhood. 
Newly  born  babes,  "runabouts,"  and  school-children  are  alike 
sufferers.  The  onset  is  usually  sudden,  with  sneezing  and  with  diffi- 
culty in  breathing  through  the  nose.  This  may  continue  for  a  few 
hours,  in  some  cases  for  a  day  or  two,  when  a  mucous,  watery,  nasal 
discharge  appears.  On  account  of  its  interference  with  nursing, 
infants  are  the  greatest  sufferers ;  breathing,  which  has  to  be  carried 


230  DISEASES    OF    THE   RESPIRATORY   TRACT 

on  largely  through  the  mouth,  is  difficult,  and  nursing,  in  consequence, 
frequently  interrupted.  There  may  be  a  degree  or  two  of  fever 
at  the  commencement  of  the  attack,  but,  as  a  rule,  it  lasts  only  a 
few  hours.  Neglected  cases  sometimes  become  infected  with  pyo- 
genic bacteria  and  a  troublesome  purulent  rhinitis  results.  In 
the  majority  of  the  neglected  cases,  however,  and  in  some  of  those 
that  are  well  treated,  this  is  the  beginning  of  an  inflammatory  pro- 
cess which  involves  successively  the  fauces,  tonsils,  larynx,  and 
bronchi.  Repeated  attacks  doubtless  aid  in  the  production  of  adenoid 
growths  in  the  nasopharyngeal  vault. 

Differential  Diagnosis. — Acute  simple  rhinitis  is  to  be  differen- 
tiated from  specific  rhinitis,  which,  as  is  well  known,  is  one  of  the  first 
manifestations  of  congenital  syphilis.  When  due  to  syphilitic  infec- 
tion, the  condition  is  uninfluenced  by  the  usual  treatment.  There  is 
no  tendency  for  it  to  descend  and  involve  the  mucous  membrane 
of  the  bronchi.  The  hoarseness  of  congenital  syphiUs  is  chronic  and 
of  gradual  development.  Furthermore,  if  the  rhinitis  is  due  to  syph- 
ihs,  other  signs  are  present,  or  will  soon  appear,  which  will  make  the 
diagnosis  possible.  Measles  almost  invariably  begins  as  an  acute 
rhinitis.  The  accompanying  conjunctivitis,  the  hard,  dry,  hacking 
cough,  and  the  characteristic  rash  soon  make  the  diagnosis  possible. 
In  nasal  diphtheria  there  is  invariably  a  discharge  from  the  nose 
which  may  be  differentiated  from  simple  rhinitis  by  the  fact 
that  the  discharge  in  diphtheria  is  excoriating  in  character  and  is 
often  tinged  with  blood.  A  diphtheritic  discharge  may  be  limited 
entirely  to  one  nostril  or  may  be  greater  from  one  nostril  than  the 
other;  while  in  acute  simple  rhinitis  the  amount  of  the  discharge  is 
usuallv  the  same  from  both  sides.  The  tendency  in  acute  simple 
rhinitis  in  a  strong  child  is  toward  recovery  in  five  or  six  days. 
When  the  surroundings  are  unfavorable,  or  in  dehcate,  rachitic 
children,  active  treatment  will  be  required  to  bring  about  a  prompt 
recovery. 

Treatment. — In  the  first  stage,  that  of  engorgement,  much  may 
be  accomplished  in  the  very  young  by  local  measures — menthol,  one 
grain,  dissolved  in  one  ounce  of  liquid  albolene.  Of  this  solution 
three  drops  are  instilled  into  each  nostril  every  hour  by  means  of  a 
medicine-dropper.  This  treatment  alone  will  relieve  the  patient  of 
a  distressing  obstruction,  thus  opening  the  way  to  freer  breathing. 
In  older  children  a  spray  containing  one  grain  of  menthol  to  an 
ounce  of  liquid  albolene  may  be  used  at  intervals  of  two  or  three 
hours. 

In  case  menthol  and  albolene  are  not  at  hand,  melted  white 
vaselin  may  be  used  in  the  same  way. 

For  internal  use  the  following  medication  has  served  me  well: 


ACUTE    RHINITIS  23I 

For  a  child  three  months  of  age : 

I^.     Tincturae  belladonnae gtt.  vij 

Pulveris  camphorae   gr-  iv 

Sacchari  lactis,  q.  s. 

M.  div.  et  ft.  tablets  No.  xxx. 

Sig. — One  tablet  every  two  hours. 

Six  months  of  age: 

I^.     Tincturse  belladonnae gtt.  x 

Pulveris  camphorae gr.  v 

Pulveris  Doveri gr.  iv 

Sacchari  lactis,  q.  s. 

M.  div.  et  ft.  tablets  No.  xxx. 

Sig. — One  every  two  hours  in  water. 

From  one  to  two  years  of  age : 

I^.     Tincturae  belladonnae gtt.  xv 

Pulveris  camphorae gr-  vj 

Pulveris  Doveri gr.  x 

M.  div.  et  ft.  tablets  No.  xxx. 

Sig. — One  every  two  hours. 

At  least  six  doses  should  be  given  in  the  twenty-four  hours. 
From  two  to  four  years  of  age: 

I^.     Tincturae  belladonnae gtt.  xv 

Pulveris  camphorae Sf-  vj 

Pulveris  Doveri gr.  xv 

Sacchari  lactis,  q.  s. 

M.  div.  et  ft.  tablets  No.  xxx. 

Sig. — One  every  two  hours. 

If  for  any  reason  the  tablets  cannot  be  prepared,  powders  will 
answer  the  purpose  equally  well. 

The  above  prescriptions  are  indicated  for  the  second  or  catarrhal 
stage,  a  condition  in  which  we  usually  find  the  patient  when  brought 
for  treatment.  In  their  use  we  must  guard  against  the  constipa- 
ting effects  of  the  camphor  and  the  Dover's  powder. 

I  would  warn  here  against  the  forcible  use  of  the  syringe  in 
the  treatment  of  nasal  disorders,  or  any  form  of  nasal  irrigation 
with  any  of  the  saline  solutions  which  requires  force  for  its  use. 
Infection  is  easily  carried  into  the  eustachian  tubes  which  may  be 
the  starting-point  of  very  grave  complications,  a  suppurative  otitis 
being  thus  very  easily  produced. 

Mothers  should  be  instructed  to  use  an  enema  of  warm  sweet- 
oil  or  soapsuds  if  the  bowels  do  not  move  once  in  twenty-four  hours. 
In  children  of  a  markedly  constipated  habit  the  Dover's  powder 
may  be  omitted.  Internal  medication,  if  begun  early  and  properly 
carried  out,  will  not  be  needed  for  more  than  two  or  three  days. 
During  an  attack  of  acute  rhinitis,  the  child  should  not  be  unneces- 
sarily exposed  to  cold,  as  there  is  a  strong  tendency  for  the  disease 
to  descend  and  involve  other  portions  of  the  respiratory  tract. 


232  DISEASES    OF    THE    RESPIRATORY   TRACT 

CHRONIC  RHINITIS  ?  NASAL  CATARRH 
A  nasal  discharge,  more  or  less  constant,  is  present  in  not  a  few 
children  during  their  entire  child  life.  In  the  majority  this  dis- 
charge begins  with  the  onset  of  cold  weather  and  lasts  until  spring. 
It  may  be  composed  of  thin,  watery  mucus,  or  it  may  be  muco- 
purulent in  character. 

It  may  be  due  to  several  causes,  which  will  be  given  in  the  order 
of  their  frequency;  for,  in  order  to  treat  this  condition  successfully 
the  source  of  the  discharge  must  be  discovered : 

1.  Adenoids  in  the  nasopharyngeal  vault. 

2.  Hypertrophy  of  the  turbinated  bones,  with  septal  deviations, 
and  hypertrophy  of  the  mucous  membranes. 

3.  Infection  due  to  pyogenic  bacteria.  When  present  it  may 
follow  an  acute  rhinitis,  but  it  is  more  often  the  sequel  of  one  of 
the  infectious  diseases.  The  discharge  may  be  distinctly  purulent 
and  is  often  very  profuse. 

4.  Infection  due  to  the  Klebs-Loeffler  bacillus.  I  have  seen 
ten  cases  in  children  from  four  to  eight  years  of  age  in  which  there 
was  a  serous  discharge  from  one  or  both  nostrils,  which  had  per- 
sisted for  a  considerable  period  of  time,  in  one  for  an  entire  year. 
Examination  of  the  discharge  showed  it  to  contain  the  Klebs-Loeflfler 
bacillus.  These  children  were  not  ill,  and  were  brought  to  us  for 
the  discharge  alone.  Such  cases  do  not  clear  up  under  the  ordinary 
methods  of  treatment,  but  promptly  respond  when  from  1500  to 
2000  units  of  diphtheria  antitoxin  are  given. 

5.  With  hay-fever  there  is  a  periodic  discharge  which  may  be 
said  to  be  chronic  in  character,  extending  over  several  weeks. 

6.  Malnutrition.  A  thin,  watery  discharge  apparently  due  to 
relaxed  mucous  membranes  is  seen  in  weak  and  poorly  nourished 
children,  with  no  other  symptom  to  explain  the  trouble  except 
the  general  weakness. 

7.  Foreign  bodies.  A  foreign  body  in  either  nostril  will  produce 
a  persistent  discharge.  When  a  child  is  brought  to  me  with  a 
history  of  a  persistent  serous  or  purulent  discharge  from  one  nostril, 
I  invariably  examine  for  a  foreign  body,  and  repeatedly  I  have 
found  this  discharge  explained  by  the  presence  of  a  pea,  a  bean, 
a  piece  of  coal,  or  a  button.  A  few  weeks  ago  at  the  out-patient 
department  of  the  Babies'  Hospital,  a  child  three  years  of  age  was 
brought  in  because  of  a  persistent  right-sided  nasal  discharge 
which  had  existed  for  seven  months.  Examination  showed  that 
there  was  a  foreign  body  well  up  in  the  nostril.  This  was  removed 
with  considerable  difficulty  and  proved  to  be  a  piece  of  cork. 

In  these  cases  of  chronic  rhinitis  the  possibility  of  adenoids 
(see  page  426)  should  never  be  forgotten;  for  they  cannot  be 
excluded  because  a  child  is  not  a  mouth-breather  and  does  not 


RECURRENT   CORYZA    AND   ANGINA  233 

snore.  Given  a  child  with  a  chronic,  so-called  "cold  in  the  head," 
and  you  will  almost  invariably  find  a  child  with  adenoid  vegetations 
in  the  nasopharyngeal  vault.  Examination  may  reveal  the  naso- 
pharyngeal space  blocked  by  the  growth,  so  that  the  entrance  with 
the  finger  is  almost  impossible,  or  there  may  be  but  a  small  pulpy 
mass,  or  a  ridge  or  soft,  friable  growth  at  the  upper  portion  of  the 
vault,  not  large  enough  to  produce  signs  of  obstruction,  but,  actively 
secreting,  it  proves  to  be  the  source  of  the  discharge.  Children 
who  have  anterior  nasal  defects,  such  as  hypertrophies  of  bone  or 
thickening  of  the  membranes,  will  usually  have  adenoids  as  well. 
In  fact,  adenoids  play  no  small  part  in  most  of  the  catarrhal  affec- 
tions of  the  upper  respiratory  tract  in  children,  and  an  examination 
of  a  child  with  a  nasal  discharge  or  a  cough  which  is  difficult  to 
account  for,  is  never  complete  without  an  exploration  of  the  naso- 
pharyngeal vault. 

Treatment. — The  treatment  consists  in  correcting  the  condition 
which  causes  the  discharge.  If  adenoids  are  present  in  a  sufficient 
amount  to  cause  trouble,  they  should  be  removed  (page  427).  No 
other  treatment  is  of  any  avail.  For  deformities  and  hypertrophies 
of  the  anterior  nasal  structure,  operative  measures  are  also  essential, 
but  should  be  carried  out  by  one  skilled  in  rhinoplastic  work.  Puru- 
lent rhinitis,  primary  or  following  the  infectious  diseases,  is  best 
treated  by  a  spray  composed  of  liquid  albolene,  one  ounce,  ichthyol 
ammonia  sulphate,  two  grains,  which  should  be  thoroughly  shaken 
before  using.  This  should  be  used  as  a  spray  every  two  hours 
while  the  child  is  awake.  Once  or  twice  a  day  it  may  be  well,  if 
the  secretion  is  profuse  and  purulent,  to  instil  into  the  nostril  about 
20  minims  of  a  one-to-six  aqueous  solution  of  hydrogen  peroxid. 
If  the  Klebs-Loeffler  bacillus  is  present,  antitoxin  alone  will  control 
the  disease,  and  that  very  promptly. 

The  anemic  and  malnutrition  cases,  which  show  almost  no  ab- 
normality, but  suffer  more  or  less  from  a  constant  serous  discharge, 
are  benefited  by  constitutional  measures  only — a  drv  climate,  plain, 
nourishing  food,  iron,  cod-liver  oil,  massage,  and  salt  baths.  Their 
management  is  referred  to  in  detail  under  The  Management  of 
Delicate  Children  (page  142).  In  these  children,  local  treatment 
other  than  that  of  cleanliness  is  a  loss  of  time  and  energy.  The 
operation  for  the  removal  of  adenoids,  the  treatment  of  hay-fever, 
and  the  methods  of  removing  foreign  bodies  from  the  nostrils  are 
all  referred  to  under  their  respective  headings. 

RECURRENT  CORYZA  AND  ANGINA 
Occasionally  we  see  patients  in  whom  there  is  a  history  of  fre- 
quent so-called  "colds"   with  fever,  profuse  nasal  discharge,   and 
sore  throat.     Several  attacks  occur  each  winter  and  usually  two 
or   three    during   the    summer    months.     Adenoids    probably    were 


234  DISEASES    OF    THE    RESPIRATORY   TRACT 

present  originally  and  possibly  enlarged  tonsils;  but  after  their 
removal  the  attacks  persisted,  though  perhaps  they  were  less  fre- 
quent and  less  prolonged.  Still  the  tendency  to  coryza  was  by 
no  means  obviated  and  the  parents  are  vigorous  in  their  denuncia- 
tion of  the  operator  and  adenoid  operations  in  general. 

These  cases  are  of  the  same  type  as  those  of  recurrent  bronchi- 
tis, and  the  suggestions  under  that  head  (page  261)  will  be  the  best 
for  us  to  follow  here. 

NASAL  HEMORRHAGE 

Nasal  hemorrhage  in  a  child  is  usually  due  to  one  of  two  sources — 
adenoid  vegetations  in  the  nasopharyngeal  vault  or  an  erosion  or 
ulceration  of  the  mucous  membrane  covering  the  free  vascular 
area  of  the  anterior  portion  of  the  nasal  septum. 

Treatment. — When  the  hemorrhage  is  due  to  an  adenoid  growth, 
it  is  usually  readily  controlled  by  keeping  the  child  in  an  upright 
position,  or  by  the  application  of  cold  to  the  back  of  the  neck — pref- 
erably by  a  piece  of  ice  wrapped  in  a  table  napkin  or  by  an  ice-bag. 
When  the  hemorrhage  is  due  to  an  erosion  of  the  septum,  pressure  of 
the  finger  on  the  outer  side  of  the  bleeding  nostril  will  effectually 
control  it,  or  the  nostril  may  be  packed  with  cotton  saturated  with  a 
5  percent  solution  of  antipyrin  or  a  i  :  2000  solution  of  adrenalin. 

For  permanent  relief,  and  to  prevent  a  recurrence  of  the  hem- 
orrhage, adenoids  should  be  removed  and  an  excoriated  or  ulcerated 
septum  cauterized  with  a  50  percent  solution  of  silver  nitrate. 
If  the  ulcer  is  first  cleaned  with  plain  water,  ordinarily  but  one  or 
two  applications  of  the  silver  solution  will  be  required.  Spraying 
the  affected  side  with  a  i  percent  solution  of  ichthyol  in  liquid 
albolene  will  hasten  the  healing  process.  As  the  ichthyol  is  not 
soluble  in  the  oil,  the  mixture  should  be  well  shaken  before  using. 

THROAT  EXAMINATION 
In  order  to  examine  the  throat  of  a  young  child  quickly  and 
thoroughly,  it  is  necessary  that  he  be  held  in  a  proper  position 
in  front  of  and  at  the  right  side  of  the  attendant,  supported  by  her 
left  arm,  beneath  the  buttocks.  Her  right  arm,  which  is  thus  left 
free,  is  passed  around  the  child,  binding  his  arms  to  his  sides  (Fig. 
22).  The  child's  head  rests  against  the  shoulder  of  the  attendant. 
The  physician  places  his  left  hand  on  the  child's  head  to  steady 
it,  and  with  the  tongue  depressor  or  teaspoon  in  his  right  hand,  with 
the  child  in  perfect  control,  the  tongue  is  pressed  downward  so 
that  it  will  not  obscure  the  field  of  vision.  With  an  older  and 
stronger  child,  it  is  best  to  bind  the  arms  to  its  sides  with  a  large 
towel  or  small  sheet.  The  most  satisfactory  view  can  be  obtained 
by  daylight  before  a  window.  If  the  examination  is  made  in  the 
evening,  a  lamp  or  taper  held  by  a  third  person,  a  little  above  and 


FAUCITIS  235 

behind  the  attendant's  right  shoulder,  will  furnish  a  satisfactory 
illumination.  The  head-mirror  should  be  used  for  children  who 
are  too  ill  to  be  taken  out  of  bed,  the  reflection  from  a  lighted  lamp 
or  candle  being  sufficient. 

FAUCITIS 
By   the   term    "faucitis  "    we    understand    an    inflammation    of 
that  portion  of  the  mucous  membrane  of  the  buccal  cavity  situated 


ITION    OF    THE    ThROAT. 


posteriorly  to  the  soft  palate  and  the  anterior  pillars  of  the  fauces, 
including  both  the  anterior  and  posterior  pillars,  the  tonsils,  and 
the  pharyngeal  wall.  The  inflammatory  process  is  superficial,  in- 
volving the  mucous  membrane  only,  so  that  the  tonsils  are  involved 
only  to  the  extent  of  the  mucous  membrane. 

Faucitis  is  always  present  in  scarlet  fever,  usually  to  a  marked 


236  DISEASES   OF    THE    RESPIRATORY    TRACT 

degree.  In  measles  it  is  also  present,  but  it  is  less  intense  in  its 
manifestations.  Its  most  frequent  appearance  is  in  connection 
with  a  summer  cold.  Every  year  in  late  May  and  June  I  am  called 
upon  to  treat  a  great  many  such  cases.  There  is  always  cough, 
dry  and  ineffective,  with  a  sHght  fever,  from  100°  to  101°  F.  The 
child  complains  of  sore  throat  and  there  is  some  discomfort  in  swal- 
lowing. Upon  inspection,  an  intense  inflammation  will  be  noticed 
involving  the  entire  visible  mucous  membrane.  In  many  cases 
the  inflammation  extends  downward  and  involves  the  larynx,  which 
will  be  indicated  by  the  hoarse,  croupy  character  of  the  cough. 
The  entire  illness  is  ordinarily  of  three  or  four  days'  duration. 

Treatment. — The  condition  is  best  relieved  by  a  purgative  of 
rhubarb  and  soda — 3  grains  of  powdered  rhubarb  and  3  grains  of  soda 
for  a  child  from  two  to  five  years  of  age.  For  a  child  under  two 
years  of  age  i  to  3  grains  of  rhubarb  and  i  to  2  grains  of  bicar- 
bonate of  soda  may  be  given.  This  in  a  child  from  one  to  three 
years  of  age  is  followed  by  a  tablet  or  powder  of  tartar  emetic  t^V 
grain,  powdered  ipecac  ^V  grain,  and  chlorate  of  potash  i  grain,  at  two- 
hour  intervals.  Older  children,  three  years  and  over,  receive  2  to  3 
grains  of  chlorate  of  potash,  9V  grain  of  tartar  emetic,  and  4V  grain 
of  ipecac  at  two-hour  intervals — six  doses  in  twenty-four  hours. 

PHARYNGITIS 

Inflammation  limited  to  the  posterior  pharyngeal  wall  is  of 
rather  infrequent  occurrence  in  young  children.  When  present, 
the  parts  present  a  reddened,  granular  appearance.  In  the  cases 
which  have  come  under  my  observation,  such  a  condition  has  always 
been  associated  with  digestive  disturbances.  The  tongue  is  usually 
coated  and  the  breath  foul.  A  dry  cough  and  frequent  attempts 
at  clearing  the  throat  are  the  usual  symptoms.  The  temperature 
is  rarely  above  101°  F.  It  is  to  be  distinguished  from  the  pharyn- 
gitis which  occurs  as  a  result  of  exposure,  in  that  only  the  posterior 
wall  is  involved,  the  adjacent  structures  remaining  unchanged. 
Thus  the  tonsils  and  pillars  of  the  fauces  and  the  soft  palate  present 
a  normal  appearance. 

The  treatment  is  to  reduce  the  diet  for  a  few  days  to  cereal 
gruels, — barley,  rice,  or  wheat, — or  to  chicken  or  mutton  broth. 
Calomel,  yV  grain  with  one  grain  of  rhubarb  after  feedings,  three 
times  a  day  for  three  days,  will  promptly  relieve  the  condition. 

TONSILLITIS 
The  onset  of  tonsillitis  is  usually  sudden.  There  may  be  a  chill, 
and  in  a  few  of  my  cases  an  attack  has  been  ushered  in  by  convul- 
sions. However,  the  usual  mode  of  onset  is  with  fever,  101°  to 
103°  F.,  lassitude,  loss  of  appetite,  and  muscular  soreness.  Young 
children  may  show  difficulty  in  swallowing  and  older  children  may 


TONSILLITIS 


237 


complain  of  pain  in  the  throat.  Not  every  case  of  tonsilUtis, 
however,  is  associated  with  pain  in  the  throat.  Inspection  re- 
veals the  tonsils  swollen  and  reddened,  covered  perhaps  with  light 
colored,  cheesy  deposits  scattered  over  the  surface.  In  some  in- 
stances the  disease  limits  itself  to  swelhng  and  redness;  in  others 
the  cheesy  deposit  is  an  early  symptom.  The  exudative  areas 
may  remain  distinct  and  single  or  they  may  coalesce,  forming  a 
pseudo-membrane.  The  duration  of  the  disease  ordinarily  is  from 
three  to  five  days.  During  the  attack  the  patient  feels  ill,  and  often 
the  prostration  is  considerable.  There  may  be  a  slight  swelling 
of  the  lymphatic  glands  at  the  angle  of  the  jaw,  but  this  is  usually 
absent.  If  there  is  a  great  deal  of  tenderness  of  the  glands  with 
a  sore  throat,  it  is  a  suspicious  sign,  and  should  make  one  examine 
very  carefully  for  diphtheria. 

Differential  Diagnosis.— Tonsillitis  must  be  differentiated  from 
tonsillar  diphtheria,  and  there  are  few  harder  problems  to  solve;  in 
fact,  in  many  cases,  early  in  the  attack,  the  solution  is  impossible 
without  a  bacterial  examination.  The  following  characteristics  of 
the  average  case  of  the  two  diseases  may  aid  us  in  differentiating. 

Tonsillitis. — Onset  sudden;  fever  high  at  onset,  102°  to  105°  F. 
Glands  at  the  angle  of  the  jaw  slightly  swollen,  if  at  all.  Exudation, 
follicular,  appears  as  small  dots;  membrane  may  form  through 
coalescence. 

Tonsillar  Diphtheria. — Onset  gradual;  fever  usually  low  at 
onset,  100°  to  102°  V.  Lymphatic  glands  at  the  angle  of  the  jaw 
considerably  swollen;  membrane  present  on  the  tonsil,  appears 
in  thin  grayish  layers  which  gradually  become  thicker  and  more 
extensive. 

Mixed  Injection. — A  case  of  mixed  infection  may  present  at 
first  a  picture  of  a  typical  tonsilHtis.  The  temperature  may  vary 
from  103°  to  105°  F.  There  is  pain  upon  swallowing,  prostration, 
and  loss  of  appetite  with  a  follicular  exudation.  The  case  remains 
stationary  for  from  twenty-four  to  forty-eight  hours,  when 
the  dots  coalesce,  forming  a  firm  membranous  deposit,  the  lymph- 
nodes  at  the  angle  of  the  jaw  enlarge,  and,  in  short,  both  the  clinical 
manifestations  and  the  bacterial  examination  show  that  we  have 
to  deal  with  a  case  of  diphtheria. 

The  cases  of  diphtheria  which  are  preceded  by  a  clinical  ton- 
sillitis are  probably  the  most  dangerous.  Such  a  case  was  primarilv 
a  tonsillitis  and  diagnosed  as  such,  and  for  several  days  considered 
to  be  only  a  tonsillitis,  in  spite  of  the  membranous  deposit  w^hich 
formed  later.  This  gives  abundant  opportunity  for  the  exposure 
of  other  children,  and  the  delay  in  making  the  diagnosis  postpones 
the  use  of  antitoxin,  rendering  the  remedy  of  little  or  no  avail  when 
finally  given.  It  is  my  rule  to  consider  as  diphtheria  every  case 
in  which  there  is  a  pseudo-membrane  on  the  tonsils,  and  to  treat  it 


238  dise;ases  of  the  respiratory  tract 

with  antitoxin  without  waiting  for  a  bacterial  examination.  Further- 
more, when  there  are  other  children  in  the  family,  I  invariably  quar- 
antine every  case  of  simple  tonsillitis. 

Treatment. — Local  treatment  of  the  diseased  parts  in  tonsillitis 
by  spraying,  swabbing,  and  painting  has  been  of  very  little  service  in 
my  hands,  particularly  in  children  under  four  years  of  age.  When 
the  child  is  held  by  force  for  such  treatment,  thoroughness  is  im- 
possible and  little  or  nothing  is  accomplished.  For  tractable  children 
and  those  old  enough  to  understand  what  is  being  done,  gargles, 
sprays,  and  irrigations  arc  useful  in  so  far  as  they  relieve  pain  and 
cleanse  the  diseased  parts.     A  useful  gargle  is  the  following: 

I^.     Sodii  salicylatis 

Sodii  biboratis 

Sodii  bicarbonatis aa  gr.  xlv 

Essentia  menthse  piperita; oj 

Aquae q.  s.  ad  5ij 

Sig. — One   teaspoonful   in   one-half   glass   of   water   at    115°   F.      Gargle 
entire  quantity  every  hour. 

A  useful  spray  is  the  following: 

I^.     Acidi  borici gr.  Ix 

Aquae  menthae  piperitae oviij 

M.     Sig. — Spray  throat  every  two  hours. 

Irrigation  of  the  throat  is  indicated  in  tonsillitis  not  only  on 
account  of  cleanliness,  but  because  of  the  relief  from  pain  which 
it  affords.  In  severe  tonsillitis,  with  much  swelHng  and  the  con- 
sequent tension,  the  pain  upon  swallowing  is  often  excruciating. 
For  the  irrigation  there  are  needed  a  fountain  syringe  and  a 
clean  tube  for  introduction  into  the  mouth.  The  child  may  lie 
down  or  sit  up,  as  preferred.  If  in  the  recumbent  position,  the 
head  should  be  turned  to  one  side,  the  mouth  resting  over  a 
pus  basin,  which  catches  the  water  as  it  passes  out  during  the 
irrigation.  If  it  is  preferred  to  give  the  irrigation  with  the  patient 
sitting  erect,  a  basin  held  under  the  chin  will  catch  the  water  as  it 
flows  from  the  mouth.  Two  pints  of  a  normal  salt  solution — one 
teaspoonful  of  salt  to  a  pint  of  water — at  115°  F.  is  placed  in  the 
bag,  which  has  previously  been  warmed.  The  bag  is  held  two 
feet  above  the  child's  head  and  the  solution  is  allowed  to  flow 
in  a  brisk  stream  against  the  swollen  parts,  until  at  least  one  pint 
of  the  solution  has  been  used.  The  irrigations  if  they  furnish  much 
reUef  may  be  repeated  in  from  four  to  six  hours. 

It  is  advisable  to  begin  the  treatment  with  a  laxative.  One 
grain  of  calomel  in  divided  doses,  one-sixth  grain  every  hour,  answers 
well.  The  child's  food  is  reduced.  If  bottle-fed,  the  milk  is  given 
one-half  strength,  one-half  quantity  of  the  milk  mixture  being 
given  with  an  equal  quantity  of  water.  The  fever,  if  high,  is  readily 
controlled  by  cool  sponging  (page  480). 


HYPERTROPHIED   TONSILS  239 

The  only  drug  which  has  appeared  to  me  to  possess  any  signal 
value  for  internal  use  in  tonsillitis  is  chlorate  of  potash.  One  grain 
at  two-hour  intervals  for  a  child  one  year  of  age;  2  grains  at  two- 
hour  intervals  for  a  child  two  years  of  age — 16  grains  in  twenty- 
four  hours;  3  grains  for  a  child  three  years  of  age — 24  grains  in 
twenty-four  hours.  I  rarely  give  more  than  3  grains  at  two-hour 
intervals  at  any  age.  I  have  used  chlorate  of  potash  in  this  way 
for  several  years,  and  I  have  never  been  able  to  associate  the  drug 
with  kidney  complications  in  one  of  the  hundreds  of  cases  in  which 
I  have  used  it.  It  is  usually  made  in  solution  with  simple  elixir 
and  water,  or  syrup  of  raspberry  and  water. 

Cold  compresses  to  the  throat  are  of  aid  in  older  children — those 
who  can  appreciate  the  necessity  of  the  treatment.  In  the  young, 
those  under  two  years  of  age,  it  is  impossible  to  keep  the  applica- 
tions in  position.  My  instructions  are  to  fold  and  soak  a  table 
napkin  in  cold  water,  40°  to  50°  F,  The  compress  should  be  about 
2^  inches  wide  and  from  four  to  five  thicknesses  of  the  material 
should  be  used.  The  water  is  pressed  out  and  the  dressing  is  placed 
under  the  jaw  so  that  the  ends  reach  to  the  ears.  The  compress 
is  held  in  position  by  a  handkerchief  or  a  piece  of  cheese-cloth, 
which  passes  over  and  around  it,  and  may  be  tied  at  the  top  of  the 
head.  It  should  be  removed  every  thirty  minutes,  wrung  out  of 
cold  water,  and  reapplied.  When  the  compress  is  put  on  as  we 
often  see  it,  wrapped  around  the  neck,  it  will  be  of  no  service,  as 
it  does  not  even  touch  the  parts  affected.  Children  who  have 
repeated  attacks  of  tonsillitis  are  put  on  anti-rheumatic  treatment 
(page  464)  in  the  intervals  between  attacks. 

HYPERTROPHIED  TONSILS 

Chronic  enlargement  of  the  tonsils  is  usually  the  result  of  several 
acute  attacks  of  tonsillitis.  A  tonsil  is  said  to  be  enlarged  when 
it  extends  beyond  the  pillars  of  the  fauces.  Enlarged  tonsils  pro- 
duce mouth-breathing,  disturbances  of  speech,  and  eustachian- 
tube  catarrh,  and  they  are  doubtless  a  factor  in  adenoid  etiology. 
Children  with  enlarged  tonsils  are  also  particularly  susceptible  to 
diphtheria.  In  the  crypts  are  harbored  myriads  of  bacteria,  which, 
under  favorable  conditions,  produce  repeated  attacks  of  acute 
inflammation:  the  pneumococcus,  the  tubercle  bacillus,  the  Klebs- 
Loeffler  bacillus,  and  many  other  pathogenic  bacteria  have  repeat- 
edly been  found  in  the  tonsillar  crypts.  Children  of  rheumatic 
inheritance  are  very  apt  to  have  enlarged  tonsils. 

Treatment. — The  treatment  consists  in  removal — excision  (see 
page  426).  Sprays,  gargles,  and  local  applications  are  of  little  or  no 
avail.  When,  for  any  reason,  the  operation  is  not  possible,  cauteriz- 
ing with  a  galvanic  cautery  is  indicated.  Several  sittings  at  intervals 
of  five  or  six  days  will  be  required,  however,  to  reduce  a  tonsil  of 


240  DISEASES   OF   THE    RESPIRATORY    TRACT 

any  considerable  size.  Occasionally  cases  are  seen  in  which  the 
tonsils  are  broad  and  flat,  with  marked  increase  of  connective 
tissue  and  dilated  crypts;  in  such  cases  when  the  tonsil  is  not  large 
enough  to  be  removed  with  a  tonsillotome  the  tonsil  punch  or 
the  cautery  may  be  brought  into  use.  A  few  sittings  will  prac- 
tically remove  the  tonsil,  and  its  possibilities  as  a  culture-field  for 
pathogenic  bacteria  is  destroyed.  The  application  of  a  5  percent 
solution  of  cocain  on  a  swab  will  render  the  cauterization  com- 
paratively painless. 

Hypertrophied  tonsils  should  be  removed  for  two  reasons:  (i) 
their  obstruction  to  respiration,  and  (2)  their  capacity  for  har- 
boring all  sorts  of  bacteria,  among  which  the  tubercle  bacillus  and 
the  Klebs-Loeffler  bacillus  are  the  most  important. 

PERITONSILLAR  ABSCESS;  QUINSY 

The  seat  of  a  peritonsillar  abscess  is  in  the  cellular  tissue  about 
the  tonsil.  It  may  be  above,  in  front  of,  or  behind  the  tonsil.  The 
disease  is  seen  rather  infrequently  in  children.  I  have  seen  but 
one  case  in  a  child  under  six  years  of  age.  It  usually  follows  a 
tonsillitis.  In  none  of  my  cases  has  it  followed  diphtheria,  scarlet 
fever,  or  measles.     The  history  is  usually  as  follows: 

The  child  has  a  tonsilHtis  with  the  usual  symptoms,  with  the 
addition  of  greatly  increased  swelling  and  pain  upon  swallowing. 
He  complains  of  pain  in  the  muscles  of  the  neck  on  the  affected 
side,  the  head  being  held  toward  that  side.  A  fairly  early  symp- 
tom is  inability  to  open  the  mouth  to  the  usual  extent.  In  the 
average  case,  inspection  reveals  a  reddened,  edematous  swelling 
slightly  above  and  in  front  of  the  tonsil,  causing  a  forward  displace- 
ment of  the  uvula.  In  a  few  instances  I  have  seen  it  develop  behind 
the  tonsil,  in  which  case  the  tonsil  on  the  affected  side  will  appear 
unduly  prominent.  This  type  of  case  is  very  apt  to  be  overlooked 
unless  a  digital  examination  is  carefully  made,  when  a  soft,  fluc- 
tuating swelling  will  readily  be  felt  behind  the  tonsil. 

Treatment. — The  treatment  is  by  incision.  This,  however,  should 
not  be  made  until  the  abscess  is  fully  developed.  If  the  incision  is 
made  too  early,  it  has  in  my  cases  invariably  closed  and  required  re- 
opening. This  closure  sometimes  occurs  even  after  a  timely  opera- 
tion, because  too  small  an  incision  is  made  and  the  contraction  of  the 
abscess  wall  necessarily  following  the  free  discharge  of  pus  and  blood 
effectually  closes  the  opening. 

For  operation  the  patient  should  be  wrapped  in  a  large  towel 
or  sheet  to  bind  the  arms  securely  to  the  sides.  He  should  sit  in 
an  upright  position  on  the  lap  of  the  attendant,  against  whose 
right  shoulder  his  head  rests.  The  left  arm  of  the  attendant  is 
passed  around  the  patient,  holding  him  firmly,  while  the  right  hand 
grasps  his  forehead.     A  Denhard  gag  of  the  0'Dw3^er  set  should 


PERITONSILLAR    ABSCESS;    QUINSY  24 1 

be  used  to  hold  the  mouth  open.  Either  by  the  use  of  reflected 
Ught  from  a  head-mirror,  or  with  the  patient  facing  a  window, 
the  operator,  using  a  guarded  bistoury,  makes  a  free  incision  in 
the  abscess  from  above  downward.  The  escape  of  a  considerable 
amount  of  blood  usually  follows  the  withdrawal  of  the  knife.  Often- 
times more  blood  than  pus  is  discharged.  This  is  particularly 
apt  to  be  the  case  if  the  abscess  is  opened  early. 

It  is  interesting  to  note  that  the  cases  which  open  spontane- 
ously never  heal  spontaneously.  In  addition  to  a  free  incision 
it  is  my  custom,  during  my  daily  visits  immediately  after  the  opera- 
tion, to  prevent  a  closure  of  the  wound  by  passing  into  it  a  director, 
and,  by  moving  it  up  and  down,  break  up  any  beginning  granula- 
tions. With  free,  uninterrupted  drainage  the  case  is  usually  well 
in  from  three  to  live  days. 

Aside  from  a  saline  laxative,  which  should  be  given  early  in 
the  attack,  internal  medication  is  valueless.  Two  drams  of  Rochelle 
salts  or  six  ounces  of  a  solution  of  citrate  of  magnesia  are  usually 
ordered.  Other  means  of  treatment  are  directed  to  the  comfort 
of  the  patient.  An  ice-bag  applied  externally  before  operation 
may  be  grateful  to  the  patient.  Our  greatest  means  of  furnishing 
relief,  however,  lies  in  the  use  of  the  hot  saline  irrigation,  and  the 
hot  gargle  where  practicable.  But  few  children  can  gargle  well 
enough  to  make  this  advantageous,  so  that  ordinarily  it  is  best 
dispensed  with.  With  the  few  cases  where  it  is  practicable,  I 
have  found  the  following  prescription  and  method  of  use  of  service: 

I^.     Sodii  bicarbonatis gr.  xlv 

Essentise  menthae  piperita? 5j 

Aquae q.  s.  ad  5  ij 

Sig. — Add  1  teaspoonful  to  6  ounces  of  water  at  120°  F.  and  gargle  entire 
quantity  every  half  hour. 

The  pain  occasioned  by  gargling  is  another  objection  to  its  use 
in  children.  A  far  more  effectual  means  of  relieving  pain  in  this 
disease,  and  one  which  causes  no  effort  and  distress  whatever,  and 
which  gives  astonishing  relief,  is  a  saline  irrigation  which  is  prepared 
and  given  as  follows:  A  heaping  teaspoonful  of  salt  is  added  to  one 
pint  of  water  at  120°  F.  This  is  placed  in  a  fountain  syringe  which 
is  previously  warmed.  A  towel  is  placed  around  the  patient's 
neck,  to  protect  the  clothing.  The  basin  is  held  under  the  mouth, 
to  catch  the  drainage.  With  everything  in  readiness,  the  bag  con- 
taining this  solution  being  hung  from  two  to  three  feet  higher  than 
the  child's  head,  the  end  of  the  rubber  tube,  a  part  of  every  foun- 
tain syringe,  without  the  hard-rubber  tip  attachment,  is  placed 
in  the  child's  mouth  and  the  hot  solution  is  allowed  to  flow  against 
the  inflamed  surfaces  until  the  entire  pint  has  been  used,  pressure 
being  maintained  upon  the  tube  so  that  the  flow  will  not  be  too 
free.  For  the  first  irrigation  or  two,  there  will  be  more  or  less  cough- 
16 


242  DISEASES   OF    THE    RESPIRATORY   TRACT 

ing,  and  the  child  may  have  to  rest  after  an  interval  of  a  few  minutes. 
After  he  becomes  accustomed  to  the  procedure  the  entire  pint 
may  be  used  without  intermission.  The  irrigations  may  be  repeated 
every  hour  and  may  be  used  as  well  after  as  before  operation.  When 
once  the  child  experiences  the  relief  afforded,  there  will  be  no  trouble 
in  repeating  the  irrigation. 

RETROPHARYNGEAL  ABSCESS;     SUPPURATIVE    RETRO- 
PHARYNGEAL ADENITIS 

A  retropharyngeal  abscess  is  usually  a  streptococcus  infection 
of  one  or  more  of  the  retropharyngeal  lymph-nodes  which  form  a 
chain  on  either  side  of  the  median  line,  posterior  to  the  pharynx 
and  between  the  pharyngeal  and  the  prevertebral  muscles.  The 
nodes  are  said  to  disappear  at  about  the  third  year  of  Ufe.  It  has 
never  been  my  privilege  to  see  a  case  in  a  child  over  three  years 
of  age.  The  disease  is  very  liable  to  be  overlooked.  Seven  of 
my  cases  had  been  treated — and  all  but  one  of  them  treated  by 
more  than  one  physician — for  something  other  than  retropharyngeal 
abscess.  This  failure  to  recognize  the  affection  has  been  com- 
mented upon  by  others,  recently  by  Morse,  of  Boston.  It  is  due 
to  two  causes:  First,  pediatric  writers  in  their  description  of  the 
disease  have  laid  down  too  narrow  and  definite  a  symptomatology; 
second,  the  lack  of  thoroughness  on  the  part  of  physicians  in  the 
examination  of  their  cases  results  in  their  failure  to  discover  the 
true  nature  of  the  case. 

In  describing  the  disease,  writers  tell  us  that  the  patient  holds 
his  head  in  a  characteristic  position,  backward  and  toward  the 
affected  side ;  that  the  breathing  is  noisy  and  stertorous  in  character ; 
that  there  is  difficulty  in  swallowing ;  that  there  are  enlarged  lymph- 
glands  at  the  angle  of  the  jaw,  and  that,  on  examination,  a  bulg- 
ing of  one  side  of  the  posterior  pharyngeal  wall  is  usually  dis- 
covered. Only  four  of  my  ca-ies  showed  the  above  combination  of 
symptoms.  All  the  cases  showed  but  two  symptoms  in  common — 
difficulty  in  swallowing  and  changed  voice.  Other  than  this  the 
cases  varied  widely,  depending  upon  the  location  of  the  abscess. 
Obviously,  an  abscess  situated  low  down  on  the  posterior  pharyn- 
geal wall  will  not  manifest  itself  in  the  same  way  as  one  high  up 
behind  the  soft  palate. 

Illustrative  Cases. — A  baby  nine  months  of  age  had  been  under 
treatment  in  one  of  the  outdoor  clinics  of  New  York  city.  A  diag- 
nosis of  adenoids  had  been  made  and  a  day  appointed  for  the  opera- 
tion. The  mother,  wishing  to  have  the  diagnosis  of  adenoids 
confirmed,  brought  the  child  to  the  out-patient  department  of  the 
Babies'  Hospital.  The  symptoms  of  mouth-breathing,  nasal  voice, 
and  sUght  difhculty  in  swallowing  had  been  present  for  a  couple  of 
weeks.     There  was  no  characteristic  position  of  the  head,  no  rigid- 


RETROPHARYNGEAL    ABSCESS  243 

ity  of  the  neck,  no  superficial  enlargement  of  the  lymphatic  glands. 
Inspection  of  the  throat  disclosed  a  bulging  forward  of  the  soft 
palate  on  the  right  side.  A  digital  examination  revealed  a  round, 
fluctuating  mass,  the  size  of  a  hickory-nut.  It  was  found  high  on 
the  posterior  pharyngeal  wall  and  almost  entirely  covered  by  the 
soft  palate.     No  adenoids  were  present. 

A  baby  two  years  of  age  had  been  ill  for  a  week  with  tonsillar 
diphtheria  and  was  thought  to  be  recovering,  when  suddenly  the 
voice  became  hoarse  and  croupy,  with  gradually  increasing  dyspnea. 
There  was  both  expiratory  and  inspiratory  obstruction,  such  as 
we  expect  in  laryngeal  diphtheria,  and  the  attending  physician, 
an  excellent  practitioner,  naturally  concluded  that  the  diphtheritic 
process  had  extended  to  the  larynx.  There  was  stiffness  of  the  neck 
but  no  nasal  obstruction.  The  voice  was  hoarse  and  croupy  in 
character.  There  was  slight  difiQculty  in  swallowing.  Inspection 
of  the  throat  with  a  dim  light  revealed  nothing  but  the  enlarged 
tonsils.  I  was  called  to  intubate,  and  finding  the  respiratory  ob- 
struction sufhcient  to  require  intubation,  I  proceeded  to  make  a 
digital  examination,  as  is  my  custom  before  intubating.  I  was 
not  a  Httle  surprised  to  find  a  soft,  fluctuating  mass  low  down  in 
the  pharyngeal  wall,  extending  below  and  pressing  against  the 
glottis.  The  abscess  was  opened,  with  immediate  relief  to  the 
obstruction. 

A  baby,  seven  and  a  half  months  of  age,  was  an  inmate  of  the 
country  branch  of  the  New  York  Infant  Asylum  during  my  service 
in  that  institution.^  My  attention  was  first  called  to  the  child 
because  of  its  difficulty  in  swallowing.  There  was  very  little  ob- 
struction, but  the  voice  was  harsh,  hoarse,  and  croupy.  About 
a  month  previous,  there  had  been  a  suppurating  submaxillary  aden- 
itis. On  examining  the  throat,  a  large  abscess  was  seen  on  the  right 
pharyngeal  wall,  extending  downward  as  far  as  could  be  seen.  This 
case  was  my  first  experience  with  retropharyngeal  abscess,  and 
a  Denhard  gag  of  the  O'Dwyer  set,  which  should  never  be  used  in 
these  cases,  was  introduced  and  the  child  held  in  an  upright  position 
by  the  assistant.  While  feeling  for  the  thinnest  point  of  the  sac 
for  a  suitable  place  for  the  incision  the  child  suddenly  stopped 
breathing,  became  Hmp  and  apparently  lifeless.  An  intubation 
tube,  the  smallest  of  the  O'Dwyer  set,  was  quickly  introduced  with- 
out the  gag.  After  several  minutes  of  artificial  respiration,  the 
use  of  oxygen,  and  free  hypodermic  stimulation  with  brandy,  respira- 
tion was  again  established.  The  first  inspiration  was  so  long 
delayed  that  we  had  almost  given  up  the  case  as  hopeless,  when 
the  first  short  gasp  occurred.  In  half  an  hour  the  child  had  suffi- 
ciently recovered  to  allow  the  opening  of  the  abscess.     This  was 

^The  case  was  reported  at  the  time  by  Dr.  Henry  E.  Tuley,  assistant  resi- 
dent physician. 


244  DISEASES   OF   THE   RESPIRATORY   TRACT 

done  without  a  gag,  with  the  tube  in  position.  After  a  copious 
discharge  of  pus,  the  tube  was  removed  and  the  child  recovered. 
In  this  case,  the  suffocation  was  due,  doubtless,  to  the  introduction 
of  the  gag  and  the  pressure  of  the  finger,  which  forced  the  pus  into 
the  lower  portion  of  the  sac,  which  extended  below  the  glottis, 
where  it  exerted  sufficient  pressure  to  prevent  the  entrance  of  air. 

A  private  patient  one  year  old  had  diphtheria — laryngeal,  fau- 
cial,  and  tonsillar.  Under  9000  units  of  antitoxin  and  intubation, 
satisfactory  progress  was  made,  and  on  the  eighth  day  of  the  illness 
the  tube  was  removed.  It  had  to  be  replaced  in  a  few  minutes 
because  of  returning  dyspnea.  Upon  replacing  the  tube  an  abscess 
was  found  in  the  right  posterior  pharyngeal  wall,  pressing  upon  and 
extending  below  the  larynx.  The  presence  of  the  tube  had  prevented 
the  recognition  of  the  abscess,  as  the  voice  and  breathing  were  per- 
fectly normal.  It  being  decided  that  this  was  the  cause  of  the 
obstruction,  the  abscess  was  evacuated,  but  the  marked  edema 
of  the  glottis  still  caused  considerable  respiratory  obstruction, 
and  the  tube  was  required  for  two  weeks  longer.  The  child  made 
a  perfect  recovery  and  is  well  and  strong  today. 

The  above  cases  are  cited  in  detail  in  order  that  the  reader  may 
the  more  fully  reahze  that  retropharyngeal  abscess  may  exist  with- 
out the  so-called  "characteristic  symptoms,"  and  also  to  emphasize 
the  fact  that  many  cases  have  been,  and  will  continue  to  be,  over- 
looked until  physicians  use  the  finger  as  an  aid  to  diagnosis  in  the 
diseases  of  the  upper  respiratory  tract.  It  is  to  be  remembered  that 
there  is  no  "characteristic  breathing"  and  no  "characteristic  posi- 
tion "  of  the  head  in  retropharyngeal  abscess.  The  disease  is  usually 
secondary  to  retropharyngeal  adenitis,  due  to  infection  from  ad- 
jacent diseased  structures.  There  is  always  fever,  101°  to  104° 
F.,  with  loss  of  appetite.  Occasionally  the  abscess  points  outward 
and  requires  external  incision. 

Treatment. — The  diagnosis  made,  there  is  but  one  means  of  treat- 
ment— incision  and  evacuation  of  the  pus.  In  order  to  do  this  it  is 
necessary  that  the  child  be  under  perfect  control.  The  arms  should 
be  bound  to  its  sides  with  a  large  towel  or  a  small  sheet  securely 
pinned.  The  child  is  held  in  an  upright  position  on  the  lap  of  the 
attendant,  who  passes  his  left  arm  around  the  child,  while  his  right 
hand  grasps  the  forehead,  drawing  the  head  for  further  support  back- 
ward against  the  right  shoulder.  The  operation  should  be  performed 
in  a  good  light — either  reflected  light  from  a  head-mirror  or  direct 
light  from  a  window.  With  a  tongue  depressor  in  the  operator's  left 
hand  the  mouth  is  kept  open,  and  with  the  tongue  out  of  the  way, 
the  right  hand  is  free  to  make  the  incision,  for  which  an  ordinary 
scalpel  is  used.  The  incision  should  be  from  above  downward  and  at 
least  one-half  inch  in  length.  A  basin  should  be  in  readiness  and  the 
attendant  instructed  to  invert  the  child  at  a  word  from  the  operator 


IRRIGATION    OF    THE;    THROAT  245 

as  soon  as  the  incision  is  made.  This  allows  the  pus  and  blood, 
which,  if  aspirated  into  the  trachea,  may  produce  fatal  results,  to 
stream  out  of  the  mouth.  While  the  abscess  is  discharging  and  the 
head  dependent,  the  clean  index-finger  of  the  operator  should  ex- 
plore the  cavity,  enlarge  the  opening,  if  necessary,  and  remove 
any  necrotic  tissue  that  may  be  present.  The  case  should  be  care- 
fully watched  for  several  days,  as  the  opening  is  liable  to  close 
before  resolution  is  complete,  particularly  if  it  has  not  been  enlarged 
with  the  finger.  Recovery  is  usually  complete  in  from  five  to  seven 
days. 

RETROPHARYNGEAL    ABSCESS    (TUBERCULOUS);    CARIES  OF  THE 
CERVICAL  VERTEBRA 

The  condition  is  usually  described  as  associated  with  idiopathic 
retropharyngeal  abscess,  though  it  should  not  be,  as  the  condition 
is  a  part  of  and  results  from  tuberculous  disease  of  the  spine,  which 
will  be  referred  to  under  the  proper  headings. 

IRRIGATION  OF  THE  THROAT 
Indications. — In  peritonsillar  abscess  or  retropharyngeal  abscess 
after  operation,  in  sloughing  ulcerative  processes  in  the  throat,  such 
as  we  see  in  diphtheria  rarely,  but  with  comparative  frequency  in 
scarlet  fever,  irrigation  of  the  throat  with  hot  normal  salt  solution 
is  of  distinct  therapeutic  value.  The  relief  to  the  pain,  particularly 
in  quinsy,  before  operation,  is  sufficient  to  warrant  its  use.  Those 
who  have  treated  thus  the  fetid  sloughing  throat  of  scarlet  fever,  for 
example,  need  no  argument  as  to  its  possible  advantages.  Acute 
suppurative  otitis  is  always  due  to  the  throat  infection.  Gargling 
in  children  is  a  measure  of  very  limited  usefulness  even  in  those 
who  do  it  well,  for  the  reason  that  the  solution  employed  scarcely 
comes  in  contact  with  the  post-pharyngeal  wall  and  the  lateral 
faucial  structures.  In  a  great  majority  of  older  children,  and  in 
all  young  children,  it  is  practically  useless  so  far  as  the  cleansing 
of  the  deeper  faucial  structures  is  concerned. 

Cervical  adenitis,  acute,  persistent,  and  suppurative,  is  the 
direct  result  of  throat  infection.  An  important  means  of  preventing 
it,  with  its  distressing  consequences,  is  an  effective  throat  toilet. 
Often  in  scarlet  fever  not  a  small  part  of  the  systemic  infection 
after  the  third  or  fourth  day  is  through  the  throat.  The  irrigation 
should  be  done  two  or  three  times  a  day  as  follows : 

Operation. — The  child  is  wrapped  in  a  sheet,  which  is  securely 
pinned,  binding  his  arms  to  his  sides.  He  rests  on  his  right  side  with- 
out a  pillow.  Directly  under  his  mouth  is  a  pus  basin  to  catch  the 
outflow.  A  new  fountain  syringe,  containing  a  hot  salt  solution,  120° 
F.,  is  suspended  about  three  feet  above  the  child's  body.  The 
largest  size  of  the  hard-rubber  rectal  tip  is  fastened  to  the  pipe  and 
the  tip  placed  between  the  child's  teeth.      The  current,  interrupted 


246  DISEASES    OF    THE    RESPIRATORY   TRACT 

every  few  seconds,  should  be  forcible  enough  to  increase  its  efficacy 
as  a  cleansing  agent,  the  volume  of  fluid  being  so  small  that  no 
inspiration  of  the  water  occurs. 

The  first  irrigations  will  arouse  more  or  less  rebellion  on 
the  part  of  the  patient  and  but  one-half  pint  of  the  solution 
need  be  used.  In  older  children  no  trouble  will  be  experienced  after 
the  relief  afforded  by  the  first  injection  is  appreciated.  In  refrac- 
tory young  children,  from  two  to  four  years  of  age,  the  assurance 
that  there  will  be  no  pain  and  a  promised  reward  will  reduce  the 
struggling  to  a  minimum.  It  is  not  to  be  expected  that  the  child 
will  not  cough;  in  fact,  a  moderate  amount  of  coughing  is  desirable, 
as  it  dislodges  the  pus  and  sloughing  tissue,  enabling  the  solution 
to  cleanse  the  parts  more  effectually. 

ACUTE  CATARRHAL  LARYNGITIS ;  SPASMODIC  CROUP 

By  acute  catarrhal  laryngitis  we  understand  an  idiopathic  ca- 
tarrhal inflammation,  involving  the  larynx  and  the  adjacent  structures. 
Nervous,  rachitic  children  are  particularly  susceptible  to  the  disease. 
Adenoids  are  often  a  predisposing  cause.  The  onset  may  be  sudden 
or  gradual.  Cases  which  are  of  a  gradual  onset  usually  follow  an 
acute  inflammatorv  condition  of  the  nasopharynx.  At  first  there 
is  usuallv  a  catarrhal  rhinitis,  the  fauces  and  larynx  becoming  suc- 
cessively involved,  requiring  two  or  three  days,  perhaps,  before 
the  laryngitis  is  well  marked.  The  temperature  is  usually  not  high 
at  the  onset.  One  of  the  early  symptoms  indicating  laryngeal 
involvement  is  a  hard,  dry  cough,  croupy  and  "barking  "  in  char- 
acter. The  croupy  element  in  the  cough  increases  in  severity  to- 
ward evening. 

In  the  cases  with  sudden  onset,  the  child  retires  at  the  usual 
hour  in  apparently  good  health;  a  few  hours  later  he  wakes  with 
a  characteristic  cough.  Whether  the  case  is  of  sudden  or  gradual 
onset,  the  care  is  practically  the  same  after  the  cough  develops. 
Many  cases  stop  at  this  point.  There  is  a  severe  cough  for  a  few 
days  which  subsides  under  proper  treatment.  For  a  few  of  the 
cases,  however,  the  course  is  not  so  favorable ;  the  cough  continues, 
becoming  stridulous,  every  inspiration  being  accompanied  by  a 
loud  crowing  sound.  Occasionally  a  case  will  be  seen  with  marked 
laryngeal  obstruction,  due  to  the  swelling  and  laryngeal  spasm, 
that  will  require  intubation.  In  my  experience,  however,  this 
is  very  rare,  as  I  have  had  to  intubate  but  one  child  with  catarrhal, 
non-membranous  croup — an  infant  sixteen  weeks  old. 

Acute  laryngitis  may  be  confused  with  diphtheritic  or  mem- 
branous laryngitis.     For  differentiation,  see  page  304. 

Laryngismus  stridulus  may  be  mistaken  for  catarrhal  laryngitis. 
It  is  easy  to  differentiate,  when  one  remembers  that  there  is  no 
cough  in  uncomplicated  laryngismus  stridulus,  and  that  the  laryn- 


ACUTE    CATARRHAL    LARYNGITIS;     SPASMODIC    CROUP  247 

gcal  spasm  is  usually  associated  with  excitement,  fright,  or  some 
other  nervous  inlluence.  l"\irther,  laryngismus  stridulus  does  not 
occur  as  a  defmite  illness,  the  laryngeal  spasm,  mild  or  severe, 
occurring,  as  a  rule,  several  times  a  day,  covering  a  period  of  weeks 
or  months.  The  continued  obstruction,  always  associated  with  in- 
flammatory conditions  of  acute  catarrhal  laryngitis,  is  absent. 


Fig.  23.— Crih  Preparkd  for  Steam  Lnhai.ahon. 

Treatment. — In  the  treatment  of  catarrhal  laryngitis  in  children, 
two  factors  must  be  kept  in  mind:  First,  the  congestive  infiltration 
and  dryness  of  the  parts,  which  cause  the  metallic  cough  and  the 
stridulous  breathing;  second,  the  laryngeal  spasm,  which  is  purely 
a. nervous  manifestation,  due,  doubtless,  to  the  irritation  of  the  ter- 
minal fdaments  of  the  recurrent  laryngeal  nerves  which  supply  the 
larvnx. 


248 


DISEASES    OF    THE    RESPIRATORY   TRACT 


Not  in  every  case  of  laryngitis  in  children  by  any  means  do 
we  have  croup.  But  when  croup  is  present,  we  know  that  back 
of  it  there  is  laryngeal  spasm  with  congestion  and  inflammation. 
If  we  are  to  treat  these  cases  of  catarrhal  croup  successfully,  with 
quick  recoveries,  we  must  not  lose  sight  of  the  nervous  element, 
which  is  considerable. 

Expectorants. — For  the  simple  coughs,  without  interference  with 
respiration,  the  expectorant  and  steam  treatment  answer  admirably, 
regardless  of  the  age  of  the  child.     This  special  treatment  should  be 


Fig.  24.— The  Holt  Croup  Kettle. 


preceded  by  a  full  dose — from  one  to  three  teaspoonfuls — of  castor  oil. 
For  a  child  under  one  year  of  age  a  tablet  composed  of  tartar  emetic 
y^-Q  grain  with  powdered  ipecac  g^  grain  should  be  given  every  two 
hours — eight  doses  in  the  twenty-four  hours.  If  the  tablets  or 
powders  are  not  to  be  had,  two  drops  of  syrup  of  ipecac  may  be 
given  instead.     For  a  child  from  one  to  two  years  of  age  a  tablet 


ACUTE    CATARRHAL    LARYNGITIS;     SPASMODIC    CROUP  249 

or  powder  composed  of  yV,j  grain  of  tartar  emetic,  4V  grain  of  pow- 
dered ipecac,  |  grain  of  Dover's  powder  at  two-hour  intervals, 
eight  doses  in  twenty-four  hours.  After  the  first  day  the  treatment 
should  be  commenced  early  in  the  morning,  so  that  by  evening, 
when  the  cough  and  spasm  are  at  their  maximum,  the  full  influence 
of  the  drugs  may  be  felt.  From  the  third  to  the  sixth  year,  a  powder 
or  tablet  composed  of  tartar  emetic  gV  grain,  powdered  ipecac  3V 
grain,  and  Dover's  powder  ^  grain  should  be  given  at  two-hour 
intervals,  eight  doses  in  twenty-four  hours.  At  least  eight  doses 
of  one  of  the  above  prescriptions  should  be  given  daily,  in  order  to 
get  the  full  benefit  of  the  drugs  employed.  If  the  Dover's  powder 
produces  constipation  it  may  be  omitted,  or  a  laxative  may  be  given; 
usually  the  treatment  need  not  be  continued  more  than  two  or 
three  days.  In  case  the  attack  is  mild,  it  is  best  to  omit  the  Dover's 
powder. 

Cold  Compresses. — In  older  children  a  cold  compress  to  the  throat 
is  a  valuable  local  measure.  A  napkin  or  piece  of  old  linen  answers 
best  for  this  purpose.  It  is  so  folded  that  there  are  at  least  six  thick- 
nesses of  the  material.  This  is  moistened  with  cold  water  at  60°  F., 
wrung  thoroughly,  and  placed  against  the  neck,  under  the  jaw,  so  as  to 
extend  from  ear  to  ear.  Over  this  should  be  placed  a  piece  of  oiled 
silk  or  rubber  tissue,  and  all  held  in  position  by  a  strip  of  thin  muslin 
or  cheese-cloth,  which  should  be  brought  together  at  the  ends  and 
fastened  at  the  top  of  the  head.  The  compress  should  be  changed 
every  thirty  minutes.  In  very  young  children  this  treatment  is  rarely 
satisfactory,  for  the  reason  that  it  is  difficult  to  force  the  child 
to  allow  the  bandage  to  remain  in  place.  The  practice  of  placing 
the  compress  around  the  neck,  as  is  often  done,  is  of  no  value,  as 
it  does  not  even  touch  the  diseased  parts. 

Steam  Inhalations. — Steam  inhalations  are  effective  onlv  when  the 
patient  is  kept  in  an  enclosed  space.  The  steaming  kettle  in  the  room 
is  of  little  or  no  service.  The  easiest  and  most  practical  place  for 
the  child  is  in  its  crib,  which  should  be  covered  with  a  sheet.  An 
open  umbrella  may  be  substituted  when  a  crib  is  not  available.  Under 
the  umbrella,  which  rests  upon  the  bed,  lies  the  child,  and  covering 
all  is  a  sheet  which  is  pinned  to  the  umbrella ;  or  the  umbrella  may 
be  opened  and  placed  over  the  baby-carriage  and  draped  as  before. 
Any  means  or  apparatus  which  will  furnish  steam  and  conduct  it 
to  the  enclosed  space  containing  the  child  will  answer.  The  Holt 
croup  kettle  (Fig.  24)  is  always  to  be  used  when  obtainable.  The 
steaming  may  be  continued  for  hours,  if  required.  The  sheet  should 
be  removed  occasionally  for  a  few  moments,  in  order  to  allow  a 
change  of  air.  Usually  a  child  is  kept  under  the  tent  from  twenty 
minutes  to  one-half  hour  without  such  a  change.  The  tent  is  seldom 
so  close  as  to  prevent  all  ventilation. 

Calomel  Fumigations. — A  quicker  and  more  effectual  means  than 


250 


DISEASES   OF   THE   RESPIRATORY  TRACT 


steam  is  the  use  of  calomel  fumigations.  The  patient  is  placed  under 
a  tent  prepared  as  above.  The  Ermold  lamp,  made  especially  for  this 
purpose  (Fig.  25),  is  recommended,  but  the  ordinary  alcohol  lamp  used 
for  warming  milk  answers  every  purpose.  Ten  grains  of  calomel  are 
placed  in  any  tin  receptacle,  which  rests  or  is  held  over  the  flame. 
An  ordinary  kerosene  lamp  has  served  me  well  in  a  few  instances, 
the  calomel  being  placed  in  the  cover  of  a  tin  can  which  was  held 
by  a  pair  of  pincers  over  the  top  of  the  lamp  chimney.  Regardless 
of  the  method,  the  fumigation  must  be  constantly  watched  by 
some  competent  person,  so  as  to  avoid  the  possibility  of  igniting 
the  bedclothes.  When  the  fumes  begin  to  fill  the  tent,  the  child 
will  cough  considerably.  If  the  cough  continues  for  more  than  a 
few  minutes,  it  is  advisable  to  allow  a  portion  of  the  vapor  to  escape. 
The  calomel  will  be  consumed  in  from 
five  to  ten  minutes,  depending  upon 
the  degree  of  heat  used.  After  the 
tent  is  filled  with  the  vapor,  allow^  the 
child  to  inhale  it  for  about  one-half 
hour.  The  vapor  produces  a  free  se- 
cretion from  the  mucous  membrane 
of  the  parts  and  a  local  depletion, 
with  enlargement  of  the  lumen  of  the 
larynx  and  consequent  relief  of  the 
symptoms.  The  fumigation  may  be 
repeated  after  an  interval  of  two  or 
three  hours.  In  a  non-diphtheritic 
case  I  have  rarely  had  to  repeat  the 
inhalations  more  than  two  or  three 
times. 

Anti-spasrnodics. — In  the  cases  of 
sudden  onset,  in  which  the  spasmodic 
element  is  prominent  at  the  commence- 
ment of  the  attack  as  indicated  by  the  high-pitched  crowing  inspira- 
tion, and  in  some  extreme  cases  by  the  struggle  for  breath,  the  cyano- 
sis, the  stridor,  and  the  infrasternal  recession,  the  above  treatment 
will  not  answer.  In  such  cases  we  must  combine  an  expectorant  with 
anti-spasmodic  drugs.  A  full  dose  of  syrup  of  ipecac — one  to  two 
teaspoonfuls,  or  sufficient  to  produce  emesis — should  be  given  at  once. 
If  vomiting  does  not  take  place  in  twenty  minutes,  the  ipecac  should 
be  repeated.  After  emesis  has  taken  place,  the  antispasmodic  reme- 
dies should  be  brought  into  use.  Antipyrin  and  sodium  bromid  are 
especially  effective  at  this  stage.  Antipyrin  appears  to  have  a  direct 
sedative  action  on  the  nervous  mechanism  of  the  larynx.  To  a  child 
two  years  of  age  the  following  prescription  is  often  given : 


Fig.  25.— Ermold's  Lamp. 


LARYNGISMUS    STRIDULUS  251 

I^.     Antipyrini gr.  j 

Sodii  iaromidi gi'-  ij 

Syrupi  ipecacuanha? iijij  to  iij 

Aquae q.  s.  ad  5j 

M.     Sig. — Give  one  such  dose  every  two  hours — eight  doses  in  twenty- 
four  hours. 

To  a  child  from  three  to  six  years  of  age  may  be  given : 

I^.     Antipyrini gf.  ij 

Sodii  bromidi gr.  iv 

Syrupi  ipecacuanhas gtt.  iij 

Syrupi  rhei gtt.  xv 

Aquae q.  s.  ad  oj 

M.     Sig. — Give  one  such  dose  every  two  hours^eight  doses  in  twenty- 
four  hours. 

The  medication  and  other  treatment  are  to  be  discontinued  as 
soon  as  the  dyspnea  ceases. 

LARYNGISMUS  STRIDULUS 

Laryngismus  stridukis  is  a  spasm  of  the  larynx  occurring  most 
frequently  in  infants.  It  is  rarely  seen  after  the  first  3^ear.  The 
spasm  may  cause  a  partial  or  complete  closure  of  the  glottis. 

The  severity  of  the  symptoms  depends  entirely  upon  the  degree 
of  the  spasm.  In  the  mild  cases,  sudden  inspiratory  effort,  as  in 
coughing  or  crying  or  from  fright,  will  be  sufficient  to  bring  on  an 
attack.  The  child  gives  vent  to  a  long-drawn  inspiratory  crow 
similar  to  a  whoop  in  pertussis.  This  may  be  followed  by  apnea 
which  lasts  for  a  few  seconds,  during  which  time  the  child  becomes 
blue  in  the  face.  This  is  soon  succeeded  by  a  series  of  short  gasps, 
and  normal  respiration  rapidly  returns.  In  the  more  severe  and 
rarer  cases,  the  spasm  occurs  without  warning.  This  is  particularly 
apt  to  be  the  case  in  the  very  young — those  under  six  months  of 
age.  There  is  a  short,  quick  inspiration  and  respiration  ceases. 
The  child  becomes  blue  in  the  face,  struggles  for  breath,  and  becomes 
unconscious.  In  a  few  seconds  there  is  a  relaxation  of  the  spasm, 
accompanied  by  a  loud,  inspiratory  crow,  followed  by  two  or  three 
others  of  gradually  diminishing  intensity  until  normal  respiration 
is  re-established. 

Predisposing  Causes. — Laryngismus,  according  to  myobser\^ation, 
invariably  occurs  in  weakly  children — those  suffering  from  malnutri- 
tion and  rachitis.  Among  a  large  number  of  cases,  the  majority  of 
which  were  seen  in  dispensary  work,  I  have  never  known  one  in 
which  there  was  not  some  manifestation  of  rachitis.  The  presence  of 
adenoids,  or  any  source  of  irritation  of  the  upper  respiratorv  tract, 
increases  the  severity  of  the  spasm  and  the  number  of  the  attacks. 
Under  properly  directed  treatment  the  spasms  usually  become  less 
and  less  severe,  and  finally  disappear,  although  several  weeks  of 
treatment  may  be  necessary. 

Illustrative  Case. — A  few  years  ago,  a  child  five  months  of  age  came 


252  DISEASES    OF    THE    RESPIRATORY   TRACT 

under  my  care  on  account  of  difficult  breathing,  rachitis,  and  laryn- 
gismus. The  attacks  were  rather  infrequent — once  every  three  or 
four  days — but  they  were  very  severe,  and  in  one  of  them  the  child 
died.  There  was  no  evidence  of  enlarged  thymus  gland  in  this  case. 
In  another  child,  three  months  of  age,  the  attacks  ranged  from 
twenty  to  thirty  a  day,  and  were  controlled  only  by  a  gradual  im- 
provement in  the  child's  general  condition. 

Laryngismus  may  be  mistaken  for  whooping-cough  or  catarrhal 
croup,  or  it  may  be  associated  with  both  of  these  affections.  When 
children  with  pertussis  lose  consciousness  during  a  coughing  par- 
oxysm, the  possibility  of  laryngismus  must  be  kept  in  mind.  There 
is  always  a  mild  laryngeal  spasm  associated  with  severe  catarrhal 
laryngitis  and  whooping-cough,  and  the  value  of  sedatives  in  these 
disorders  is  explained  by  their  action  in  preventing  laryngeal  spasm. 

Treatment. — Drugs. — The  management  is  divided  into  two  parts: 
the  immediate  relief  of  the  spasm,  and  the  treatment  of  the  patient's 
debilitated  physical  condition.  From  my  observation,  the  most  satis- 
factory method  of  relieving  spasm  in  the  mild  cases — those  in  which 
the  unconsciousness  is  of  but  a  few  seconds'  duration — is  by  inverting 
the  patient  and  at  the  same  time  slapping  him  on  the  back.  Splash- 
ing cold  water  in  the  child's  face  may  be  of  advantage  in  some 
cases,  but  I  have  found  it  of  but  little  service.  In  cases  which  are 
sufficiently  prolonged  to  resist  inversion  and  slapping  on  the  back, 
a  hasty  removal  of  the  outer  clothing,  with  alternate  hot  and  cold 
tub-baths,  at  60°  F.  and  120°  F.  respectively,  have  been  successful, 
except  in  the  fatal  case  referred  to,  whose  death  occurred  during 
my  absence.  If  recovery  is  not  prompt,  intubation  or  tracheotomy 
should  be  performed,  followed  by  attempts  at  artificial  respiration. 
Between  the  attacks,  the  patient  should  receive  small  doses  of  anti- 
pyrin  and  sodium  bromid.  Under  six  months  of  age,  one -half 
grain  of  antipyrin  and  two  grains  of  sodium  bromid  may  be  admin- 
istered in  one  dram  of  cinnamon-water — six  doses  being  given 
in  twenty-four  hours.  From  the  age  of  twelve  months  to  the  third 
year,  one  to  two  grains  of  antipyrin  with  two  to  four  grains  of  so- 
dium bromid  may  be  administered  in  one  dram  of  cinnamon-water — 
six  doses  being  given  in  twenty-four  hours.  The  only  disadvantage 
in  the  use  of  these  drugs  Hes  in  the  fact  that  these  children  almost 
invariably  have  faulty  digestion,  which  condition  may  be  aggravated 
by  the  sodium  bromid.  When  this  is  observed,  the  bromid  is  best 
omitted  and  the  antipyrin  given  alone.  Antipyrin  apparently  never 
produces  any  unfavorable  effects  upon  gastric  digestion. 

Colon  medication  may  be  of  considerable  service  in  these  cases, 
and  when  indicated,  bromid  and  chloral  are  our  most  reliable  seda- 
tives. For  a  child  of  six  months  or  under,  one  grain  of  chloral 
with  three  grains  of  sodium  bromid  may  be  given  in  two  ounces 
of  mucilage  of  acacia;    for  a  child  of  from  six  to  twelve  months. 


TRAUMATIC    LARYNGITIS  253 

two  grains  of  chloral  and  five  grains  of  sodium  bromid  in  three 
ounces  of  mucilage  of  acacia;  for  a  child  of  from  twelve  to  twenty- 
four  months,  two  grains  of  chloral  and  eight  grains  of  sodium  bromid 
may  be  given  in  two  ounces  of  mucilage  of  acacia.  The  bromid 
and  chloral  should  not  be  administered  oftener  than  once  in  six 
hours. 

The  method  of  administration  is  as  follows:  A  large  soft-rubber 
catheter  or  a  small  rectal  tube  should  be  attached  to  a  Davidson 
syringe  and  introduced  at  least  nine  inches  into  the  rectum  so  as 
to  reach  the  descending  colon.  The  child  should  rest  on  its  left 
side  with  the  buttocks  elevated  on  a  pillow  so  that  they  are  higher 
than  the  shoulders.  After  the  withdrawal  of  the  tube  the  position 
of  the  child  should  be  maintained  for  several  minutes  in  order  to 
aid  in  the  retention  of  the  fluid. 

Diet. — The  dietetic  management  of  debilitated,  rachitic  children 
suffering  from  laryngismus  is  the  same  as  that  of  other  debilitated 
children.  (See  Malnutrition,  page  156.)  In  general,  they  should 
be  given  as  high  a  proteid  diet  as  is  compatible  with  their  digestive 
powers.  Thus,  if  there  is  intolerance  of  cow's  milk  given  in  suit- 
able dilution,  there  should  be  no  hesitation  in  advising  a  wet-nurse. 
Condensed  milk  or  proprietary  foods  should  not  be  given  such  a 
child,  if  better  means  of  nourishment  are  obtainable.  For  children 
over  one  year  of  age,  cow's  milk,  cereals  containing  a  large  amount 
of  nitrogen,  soft-boiled  eggs,  beef-juice,  and  scraped  beef  should 
form  a  large  part  of  the  diet.  Particularly  must  these  children 
be  kept  free  from  all  sources  of  excitement,  such  as  loud  talking, 
the  over-attention  of  adults,  and  the  rough,  active  play  of  older 
children. 

TRAUMATIC  LARYNGITIS 

Traumatic  laryngitis,  while  a  very  rare  condition  in  children,  is 
occasionally  met  with.  It  may  be  caused  by  the  inhalation  of  steam 
or  irritating  gases  or  the  aspiration  of  carbolic  or  other  strong  acids. 

I  once  saw  a  fatal  case  due  to  the  aspiration  of  pure  carbolic 
acid  by  a  child  three  years  of  age  who  was  given  a  teaspoonful 
of  the  acid  by  a  five-year-old  sister.  As  soon  as  it  passed  her  lips 
the  child  cried  and  coughed.  None  of  the  acid  was  swallowed, 
apparently,  but  sufficient  was  aspirated  into  the  larynx  to  produce 
intense  congestion  and  sufficient  edema  to  require  immediate  opera- 
tive measures.  The  parts  sloughed  extensively  and  the  child  died 
in  two  weeks  from  pneumonia,  resulting  from  sepsis. 

Treatment. — No  case  of  corrosive  injur}' to  the  mucous  membrane, 
sufficient  to  produce  congestion  and  edema  with  a  resulting  inspiratory 
obstruction  which  requires  operative  rehef,  should  ever  be  intubated 
except  as  a  temporary  expedient,  since  the  presence  of  a  tube  will 
invariably  cause  extensive  sloughing.     If  the  case  is  urgent,  trache- 


254  DISEASES   OF   THE   RESPIRATORY   TRACT 

otomy  is  the  only  warrantable  operation.  In  two  cases  due  to  irri- 
tating gases  —  sulphur  dioxid  in  one  case  and  steam  inhalation  in 
another^the  successful  treatment  was  the  use  of  cold  applications 
to  the  neck  by  means  of  wet  compresses  at  a  temperature  of  60°  F» 

LARYNGEAL  OBSTRUCTION 
Laryngeal  obstruction  may  be  either  complete  or  partial,  causing 
entire  cessation  of,  or  greatly  impeded,  respiration.  As  the  calls 
upon  the  physician  for  aid  in  these  cases  are  attended  with  great 
urgency,  it  is  well  to  bear  in  mind  the  conditions  which  may  give 
rise  to,  or  directly  cause,  laryngeal  obstruction.  These  are  referred 
to  in  detail  under  their  respective  headings.  In  order  of  frequency 
they  occur  as  follows: 

1.  Acute  Catarrhal  Laryngitis  (Catarrhal  Croup),  page  246. 

2.  Membranous  Laryngitis  (Laryngeal  Diphtheria),  page  304. 

3.  Retropharyngeal  Abscess  (Laryngismus  Stridulus),  page  242. 

4.  Foreign  Bodies  in  the  Larynx,  page  254. 

5.  Traumatic  Laryngitis,  page  253. 

6.  New  Growths. 

Acute  catarrhal  laryngitis,  membranous  laryngitis,  and  retro- 
pharyngeal abscess  are  by  far  the  most  frequent  causes  of  laryngeal 
obstruction  in  children.  In  children,  edema  is  a  very  infrequent 
cause  of  laryngeal  obstruction;  it  is  a  complication  or  a  sequel 
of  other  pathologic  states;  for  example,  it  may  result  from  an 
inflammation  accompanying  a  low-placed  retropharyngeal  abscess^ 
a  traumatic  laryngitis  after  the  inhalation  of  irritating  gases,  or  from 
the  aspiration  of  corrosive  fluids  or  powders. 

FOREIGN  BODIES  IN  THE  LARYNX 
Foreign  bodies  are  usually  lodged  in  the  larynx  by  an  act  of 
sudden  inspiration  attended  by  a  quick  forward  movement  of  the 
head,  as  in  coughing  or  laughing  with  a  foreign  body  in  the  mouth 
or  between  the  teeth.  The  patient  is  immediately  seized  with  a 
violent  paroxysm  of  coughing  and  suffocation,  the  severity  of  which 
depends  upon  the  size  and  shape  of  the  foreign  body. 

Inversion  of  the  patient  was  of  no  service  whatever  in  the  cases 
seen  by  me.  The  first  thing  to  do  is  to  introduce  into  the  mouth 
the  index-finger,  with  the  hope  that  a  portion  of  the  mass  may 
protrude  sufficiently  to  make  possible  its  removal.  Should  this 
fail,  a  laryngeal  forceps  should  be  brought  into  use,  its  introduction 
being  guided  and  guarded  by  the  index-finger.  When  this  is  not 
successful,  tracheotomy  should  be  performed  to  relieve  the  child 
from  immediate  danger  of  suffocation,  after  which  further  surgical 
procedures  may  be  considered.  Intubation,  it  is  hardly  necessary 
to  state,  should  not  be  attempted. 


PERSISTENT   COUGH  255 

PERSISTENT  COUGH 

I  have  had  occasion  to  examine  and  treat  many  children  who 
were  brought  to  me  because  of  a  "cough"  which  had  not  been 
controlled  by  the  measures  employed.  The  history  is  usually  only 
that  of  a  persistent  cough.  It  may  be  irritating  in  character,  keep- 
ing the  child  awake  at  night,  or  it  may  be  paroxysmal,  the  attacks 
being  more  severe  when  the  child  is  lying  down.  Manv  times  the 
paroxysms  are  so  severe,  being  particularly  worse  at  night,  that 
whooping-cough  is  suspected  because  of  the  absence  of  chest  signs. 

While  we  hear  much  of  the  cough  of  teething,  the  "stomach 
cough,"  the  "nervous  cough,"  and  the  "habit  cough,"  it  has  never 
been  my  lot  to  see  a  case  in  which  the  cough  was  not  connected  in 
some  way  with  the  respiratory  tract.  Thorough  examination  of  these 
cases,  perhaps  repeated  examinations,  will  be  required  before  the  site 
of  the  trouble  is  definitely  located,  when  it  will  invariably  be  found 
somewhere  between  the  anterior  nares  and  the  thorax.  The  stomach 
cough,  the  nervous  cough,  or  the  teething  cough  formerly  stood  for 
the  persistent  cough  which  could  not  be  accounted  for  by  phvsical 
examination  of  the  chest  or  by  mere  inspection  of  the  throat.  They 
are  frequently  referred  to  by  the  older  writers. 

An  adherent  pleura  and  enlarged  tonsils  without  adenoids  are  ac- 
countable for  a  very  small  number  of  these  cases.  An  elongated 
uvula,  to  which  these  obscure  coughs  have  also  been  attributed,  is 
very  rarely  a  cause. 

An  immense  majority  of  these  obscure  coughs  in  children  are 
due  to  adenoid  vegetations  with  or  without  enlarged  tonsils.  A 
child  with  such  a  cough  may  have  the  typical  adenoid  face,  mouth- 
breathing,  and  other  signs  referred  to  (see  Adenoids,  page  426), 
or  these  symptoms  may  be  entirely  absent.  It  is  the  latter  type 
of  case  that  is  particularly  puzzling  and  apt  to  be  overlooked.  On 
account  of  the  absence  of  mouth-breathing  and  other  svmptoms 
of  nasal  obstruction,  the  possibility  of  adenoid  vegetations  has  been 
ignored.  In  these  cases  careful  inquiry  will  usually  elicit  the  his- 
tory of  frequent  colds,  or  what  is  styled  "catarrh,"  as  there  is  more 
or  less  serous  discharge  from  the  nose,  or  the  child  is  said  to  "take 
cold  in  the  head  easily."  Digital  examination  of  the  nasopharyn- 
geal vault  will  reveal  a  fringe  of  soft  adenoid  growth  at  the  upper 
portion  of  the  posterior  pharyngeal  wall,  not  large  enough  to  pro- 
duce obstruction,  but  actively  secreting.  This  secretion,  if  not 
profuse,  is  partially  evaporated  in  the  nostrils,  or  if  profuse,  is 
discharged  from  the  nostrils  or  passes  backward  over  the  posterior 
pharyngeal  wall,  thus  provoking  cough,  when  the  child  is  up  and 
about.  When  the  child  rests  on  his  back,  the  secretion  naturally 
flows  over  the  posterior  pharyngeal  wall,  and  a  cough  is  the  result. 
Time  and  again  I  have  relieved  the  most  obstinate  cough  by  curet- 


256  DISEASES   OF    THE    RESPIRATORY   TRACT 

ting  and  removing  this  sponge-like  tissue.  In  one  patient,  a  boy- 
two  years  of  age,  who  had  been  coughing  hard  for  ten  days  with 
paroxysms  and  vomiting,  a  diagnosis  of  pertussis  had  been  made 
by  a  member  of  the  family  who  had  seen  many  cases  of  whooping- 
cough,  and  also  by  myself.  Adenoids  were  found  to  be  present 
in  a  slight  degree.  Their  removal  was  advised,  with  the  idea  of 
making  the  coughing  attacks  less  severe,  when,  greatly  to  our  sur- 
prise, the  coughing  ceased  at  once,  not  a  paroxysm  occurring  after 
the  growth  was  removed.  The  cough  was  due  to  the  adenoid  vege- 
tations and  not  to  pertussis. 

Adherent  pleura,  non-tuberculous,  as  previously  mentioned,  is 
occasionally  a  cause  of  persistent  cough.  Autopsies  upon  children 
dying  with  diseases  other  than  respiratory  often  show  these  pleuritic 
adhesions,  which  are  not  suspected  during  life.  A  little  girl  twelve 
years  of  age  was  brought  to  me  because  of  a  persistent  cough.  The 
child  was  otherwise  well  and  gaining  in  weight.  She  had  been 
treated  with  expectorants,  cod-liver  oil,  and  the  usual  medication, 
without  avail.  The  cough  remained  unchanged  and  was  influenced 
only  by  opiates.  A  very  careful  physical  examination  revealed 
friction  rales,  covering  an  area  the  size  of  a  half  dollar,  at  the  base 
of  the  right  lung  adjacent  to  the  spine.  They  were  heard  only  on 
forced  inspiration  and  had  been  overlooked  in  the  previous  exami- 
nation.    It  had  been  diagnosed  as  a  "nervous  cough." 

Tracheitis  will  produce  a  cough,  severe  and  intractable,  with 
no  signs  in  the  chest.  In  these  cases,  however,  there  is  no  chronic- 
ity,  the  cough  being  sudden  in  its  development.  It  is  usually 
accompanied  by  slight  fever,  and  if  the  child  is  old  enough  he  will 
aid  us  by  referring  to  the  sense  of  discomfort  and  tightness  which 
exists  over  the  upper  portion  of  the  chest.  Sometimes  the  sensa- 
tion will  be  described  as  a  burning,  which  is  located  directly  over 
the  trachea. 

The  most  frequent  cause  of  the  temporary  cough  seen  daily 
in  children's  work  need  only  be  referred  to.  It  is  an  acute  inflam- 
matory condition  of  the  mucous  membrane  of  the  respiratory  tract, 
involving  most  frequently  the  fauces,  the  larynx,  and  bronchi. 

Incipient  tuberculous  infiltration  in  any  portion  of  the  lungs  or 
pleura  may  produce  the  persistent  cough.  Thorough  physical  ex- 
aminations and  careful  observation  of  all  the  cases  for  a  few  days 
will  make  a  diagnosis  possible. 

Pertussis  without  the  whoop  or  vomiting  may  cause  a  persistent 
cough.  It  runs  its  course  and  subsides  in  from  four  to  eight  weeks. 
A  diagnosis  is  possible  only  when  there  is  a  history  of  exposure  to 
the  disease.  The  treatment  for  the  various  conditions  producing 
cough  is  referred  to  under  their  respective  headings. 


BRONCHITIS  257 


BRONCHITIS 


Bronchitis  in  children  may  be  divided  into  three  types :  primary, 
secondary,  and  chronic. 

Primary  bronchitis  is  usually  the  result  of  exposure.  It  occurs 
in  all  classes  and  conditions  of  children.  In  New  York  city  it  is 
a  very  prevalent  disease  during  inclement  weather  and  is  indirectly 
the  cause  of  many  deaths.  Rachitic  and  otherwise  poorly  nour- 
ished children  are  particularly  predisposed  to  attacks.  The  younger 
the  child,  the  greater  the  susceptibility  and  the  more  dangerous 
the  affection. 

Secondary  bronchitis  is  most  often  associated  with  measles, 
whooping-cough,  and  bronchopneumonia,  although  it  may  be  a 
complication  of  almost  every  ailment  of  early  life. 

Chronic  bronchitis  is  somewhat  rare  in  young  children.  It 
is  seen  most  frequently  in  asthmatics,  in  slow  convalescence  after 
bronchopneumonia,  and  is  always  present  in  chronic  pulmonary 
tuberculosis. 

The  onset  of  an  acute  attack  of  bronchitis  is  usually  sudden. 
There  is  cough,  followed  by  fever  which  is  seldom  high,  occasionally 
touching  102°  F.,  but  almost  never  remaining  above  this  point 
for  any  length  of  time.  The  usual  temperature  range  is  from  100° 
to  102°  F.,  the  respirations  are  slightly  accelerated,  rarely  above 
thirty  per  minute,  and  there  is  moderate  prostration.  In  a  severe 
attack  the  appetite  is  interfered  with,  the  child  is  restless,  peevish, 
and  shows  general  discomfort.  Examination  of  the  chest  early 
in  the  attack  will  reveal  a  harsh,  rough  respiratory  murmur,  pretty 
evenly  distributed  all  over  the  lungs.  Sonorous,  sibilant,  and  the 
various  types  of  mucous  rales  make  their  appearance  in  from 
twelve  to  twenty-four  hours.  Among  thousands  of  these  cases 
I  have  never  seen  a  single  uncompHcated  bronchitis  with  a 
temperature  range  above  102°  F.  When  the  temperature  gets 
above  this  point,  or  higher,  and  remains  there,  there  has  always 
been  found  a  complication  of  some  sort — something  other  than 
the  bronchitis  to  help  account  for  the  fever.  Often  this  is  tonsilli- 
tis, gastro-enteric  disturbance,  or  a  beginning  bronchopneumonia. 
With  a  temperature  ranging  above  102°  F.  and  respirations  of  forty 
or  over,  we  may  be  almost  certain  of  a  developing  pneumonia. 

The  duration  of  an  attack  of  bronchitis  is  ordinarily  stated  to 
be  from  five  to  ten  days.  This  is  an  error.  The  duration  depends 
to  a  sUght  extent  upon  the  child,  but  to  a  much  greater  degree 
upon  the  method  of  treatment.  A  primary  case  properly  managed 
should  be  well  in  five  days.  Many  cases  are  not  treated  at  all  by 
the  physician,  because  he  is  not  consulted,  and  some  cases  even 
then  are  not  properly  treated.  It  is  these  cases  of  neglected  bron- 
chitis which  furnish  a  great  majority  of  our  cases  of  bronchopneu- 
17 


258  DISEASES   OF   THE   RESPIRATORY   TRACT 

monia,  a  disease  which  contributes  largely  to  the  mortality  of 
children  under  five  years  of  age. 

Signs  of  consolidation  in  the  lung  are  not  necessary  for  the 
diagnosis  of  pneumonia.  Cases  very  often  reported  as  capillary 
bronchitis,  in  which  there  is  rapid  breathing — 40  to  60  a  minute — 
high  temperature,  103°  to  105°  F.,  and  marked  prostration,  show 
at  autopsy  the  pneumonic  elements  which  gave  during  hfe  no  other 
signs  in  the  chest  than  a  diminished  respiratory  murmur  and  many 
fine  mucous  rales. 

Treatment. — Before  indicating  what  should  be  done  in  a  case  of 
bronchitis  it  may  be  as  important,  by  way  of  emphasis,  to  advise 
what  not  to  do.  Do  not  seal  the  room  up  tight  by  keeping  all  the 
windows  closed.  Do  not  use  an  oil-silk  jacket  lined  with  wadding  or 
any  other  material.  Do  not  allow  the  child  to  be  wrapped  in  blankets 
and  shawls  and  held  against  a  warm  adult  body.  Do  not  give  the 
child  large  doses  of  so-called  "expectorants" — a  teaspoonful  of 
a  heavy  syrup.  The  temperature  of  the  room  should  be  kept  as 
near  70°  F.  as  possible.  There  should  always  be  direct  communi- 
cation with  the  open  air.  A  window  lowered  an  inch  or  two  from 
the  top,  or  the  window-board  described  on  page  43,  is  a  safe  means 
of  assisting  in  ventilation.  The  child  should  be  kept  in  its  crib 
and  wear  the  night-clothing  it  was  accustomed  to  wear-  in  health. 
Many  children  with  bronchitis  do  not  feel  particularly  ill  and  rebel 
against  the  enforced  inactivity ;  for  such  as  cannot  be  kept  under 
the  covers,  a  pinning-blanket  or  a  bath-robe  may  be  worn  while  the 
child  sits  up  in  bed,  but  it  should  not  be  allowed  to  sleep  in  either. 

The  Diet. — If  there  is  little  or  no  fever,  the  diet  need  be  reduced 
but  Httle.  If  there  is  fever,  100°  to  101.5°  F.,  with  restlessness  and 
irritability,  the  food  should  be  reduced  in  strength,  giving  the  same 
amount  of  fluid  as  in  health,  the  reduction  being  made  by  giving 
plain  boiled  water  frequently  to  drink  between  the  feedings.  The 
diet  of  a  nursing  baby  can  best  be  reduced  by  giving  him  a  drink 
of  water  before  each  nursing,  and  shortening  the  time  allowed  for 
nursing  from  one-third  to  one-half.  We  will  thus  avoid  digestive 
disturbances,  which  often  act  as  a  very  serious  complication  to  the 
existing  disorder.  Older  children,  those  on  a  mixed  diet,  may  be 
given  toast,  cocoa,  milk,  broths,  gruels,  and  fruit-juices. 

Steam  Inhalations. — Properly  administered  medicated  steam  in- 
halations are  of  greater  service  in  bronchitis,  particularly  in  young  in- 
fants, than  anv  other  measure  of  treatment  which  we  possess.  The 
steaming  is  best  administered  when  the  child  is  placed  in  its  crib,  which 
is  covered  and  draped  with  sheets.  The  croup  kettle  (Fig.  26)  with 
alcohol  lamp  attachment  is  the  most  convenient  means  for  genera- 
ting steam.  The  nozzle  of  the  croup  kettle,  which  rests  on  a  chair  or 
stand,  is  carried  under  the  tent  at  a  safe  distance  from  the  child's 
hands  and  face.     For  inhalation,  creosote  has  given  better  results 


BRONCHITIS 


259 


than  has  any  other  drug.  Ten  drops  are  added  to  one  quart  of 
boiling  water  and  the  steaming  continued  for  thirty  minutes.  Ordi- 
narily, in  an  urgent  case,  steaming  of  thirty  minutes  is  given  at 
two-and-a-half-hour  intervals  day  and  night  until  the  child  recovers. 
Older  children  and  those  in  whom  the  condition  is  not  grave  need 
not  be  steamed  after  the  bedtime  of  mother  or  nurse.  It  is  well 
to  allow  a  change  of  air  in  the  enclosed  space  at  least  three  times 
during  the  steaming.  This  is  done  by  raising  the  sheet  for  a 
moment  or  two  and  then  replacing  it. 

Counter-irritation. — Counter-irritation  of  the  skin  over  the 
thorax  is  another  very  useful  method  of  treatment  in  bronchitis. 
Full  instructions  must  be  given  the  mother  and  nurse  as  to  how  the 
counter-irritant  is  to  be  applied,  or  the  application  will  be  very  indiffer- 
ently made.  In  my  hands  the  mustard  plaster  (page  493)  has  been 
the  most  convenient  means  of  counter-irritation,  and  has  given  the  best 
results.  It  is  well  to  begin  with  a  strength 
of  one  part  of  mustard  and  two  parts  of 
flour.  Two  or  three  applications  of  this 
strength  may  be  made.  Later,  when  the 
skin  becomes  sensitive,  the  plaster  is  made 
weaker  by  the  addition  of  more  flour,  one 
part  of  mustard  to  five  or  six  of  flour. 
In  order  to  be  effective  the  plaster  should 
remain  in  contact  with  the  skin  from  five 
to  fifteen  minutes,  until  a  diffuse  blush 
appears.  The  plaster  is  prepared  as  fol- 
lows: Mix  the  mustard  and  the  flour, 
using  hot  water  until  a  paste  of  medium 
thickness  is  formed.  This  is  to  be  spread 
on  cheese-cloth,  old  linen,  or  thin  white 
muslin,  to  a  thickness  of  about  ^  of  an  inch. 

Over  this  one  thickness  of  cheese-cloth  is  placed.  The  size  of  the  plas- 
ter depends  upon  the  age  of  the  child  and  the  area  of  lung  involved. 
In  a  case  of  general  bronchitis  the  entire  thorax,  front  and  back, 
should  be  covered.  It  is  easier  to  make  two  plasters  which  meet 
under  the  arms  than  to  make  one  to  encircle  the  thorax,  as  is  some- 
times done.  A  circle  is  cut  out  for  the  arms  at  the  upper  corners. 
The  plasters  are  sufficiently  large  to  meet  at  the  sides,  as  mentioned 
above,  when  they  may  be  pinned  together.  When  all  is  completed, 
it  really  amounts  to  a  mustard  jacket.  The  plaster  may  be  applied 
from  two  to  four  times  daily,  depending  upon  the  urgencv  of  the 
case.  Counter-irritation  thus  made  is  of  great  service  early  in  the 
attack — during  the  stage  of  acute  congestion.  I  question  whether 
plasters  are  of  much  use  after  two  or  three  days  have  elapsed.  After 
removing  the  plaster  an  apphcation  of  vaseHn  is  grateful  to  the 
patient. 


in.  26. — Croup  Kettle  with 
Alcohol  Lamp  Attachment. 


26o  DISEASES   OF   THE    RESPIRATORY   TRACT 

Mustard  Baths. — A  mustard  bath  (page  30),  \  ounce  of  mustard 
to  6  gallons  of  water  at  a  temperature  of  110°  F.,  is  of  considerable  ser- 
vice in  the  very  acute  cases  in  young  children  with  extensive  involve- 
ment of  the  fine  tubes — a  type  of  case  usually  known  as  "capillary  bron  - 
chitis."  These  cases  are  very  apt  to  develop  into  bronchopneumonia, 
if  they  are  not  such  from  the  beginning.  There  is  considerable 
shock,  the  hands  and  feet  are  often  cold,  the  respiration  rapid,  and 
the  child  considerably  prostrated.  The  bath  may  be  repeated  with 
advantage  at  intervals  of  from  six  to  eight  hours.  It  will  not  be  of 
value  after  forty-eight  hours. 

Drugs. — The  value  of  drugs  in  the  management  of  this  disease  has 
been  considerably  overestimated,  and  they  are  mentioned  last  because 
they  are  the  least  important  of  the  remedial  measures  referred  to. 
During  the  first  stage  of  bronchitis,  that  of  engorgement,  indicated 
by  a  short,  dry  cough,  and  rough,  sonorous  breathing  on  auscultation, 
small  doses  of  castor  oil  and  syrup  of  ipecac  furnish  us  our  best 
medication;  from  the  first  to  the  third  year,  two  to  three  drops 
of  castor  oil  and  two  to  three  drops  of  syrup  of  ipecac  may  be 
given  every  two  hours;  after  the  third  year,  three  drops  of  syrup 
of  ipecac  and  five  drops  of  castor  oil  every  two  hours.  At  least 
eight  doses  should  be  given  in  twenty-four  hours.  Ordinarily,  after 
twenty-four  hours,  auscultation  will  reveal  a  freer  secretion  in  the 
bronchi,  the  fever  will  diminish,  and  the  child's  cough  will  become 
loose  and  less  severe.  The  benefits  from  the  oil  and  ipecac  will  be 
accomplished  in  from  forty-two  to  seventy-two  hours,  when  this 
medication  should  be  discontinued. 

If  the  cough  and  the  chest  sounds  tell  us  that  the  bronchi  are 
not  yet  clear,  a  combination  of  tartar  emetic,  powdered  ipecac, 
and  ammonium  chlorid  may  be  used.  For  a  child  under  six  months 
of  age  a  powder  or  tablet  containing  yio  grain  of  tartar  emetic, 
gV  grain  of  powdered  ipecac,  and  \  grain  of  ammonium  chlorid  should 
be  given  at  two-hour  intervals,  eight  doses  in  twenty-four  hours; 
from  six  months  to  one  year,  tartar  emetic  y^^  grain,  powdered 
ipecac  ^V  grain,  ammonium  chlorid  \  grain,  at  two-hour  intervals, 
eight  doses  in  twenty-four  hours.  If  the  cough  is  very  annoying 
and  severe,  requiring  a  sedative,  |  grain  of  Dover's  powder  may 
be  added  to  each  dose  for  children  under  six  months  and  \  grain 
for  children  over  six  months  of  age.  From  one  to  three  years  of 
age,  tartar  emetic  y^  grain,  powdered  ipecac  yV  grain,  ammonium 
chlorid  \  grain  at  two-hour  intervals,  eight  doses  in  twenty-four 
hours,  h,  grain  of  Dover's  powder  to  be  added  to  each  dose  if  the  char- 
acter of  the  cough  demands  it.  The  tablet  or  powder,  whichever 
is  employed,  should  be  given  in  two  teaspoonfuls  of  thin  gruel  or 
plain  water.  After  the  third  year  -§-V  grain  of  tartar  emetic,  2V 
grain  of  pulverized  ipecac,  and  i  grain  of  ammonium  chlorid  may  be 
given  every  two  hours,  eight  doses  in  the  twenty-four  hours.     The 


RECURRENT    BRONCHITIS  26  I 

use  of  tablets  or  powders  should  be  insisted  upon,  particularly  in 
very  young  children.  The  large  doses  of  ammonium  salts  and 
ipecac  in  heavy  syrups  are  to  be  avoided  because  of  their  Hability 
to  produce  stomach  disturbance. 

The  treatment  of  secondary  bronchitis  depends  to  a  certain 
extent  upon  the  disease  with  which  it  is  associated,  and  the  treat- 
ment should  be  modified  accordingly.  Counter-irritation  and  medi- 
cated steam  inhalations  ordinarily  can  be  used,  as  they  interfere  but 
little  with  other  necessary  treatment. 

In  chronic  bronchitis  the  removal  of  enlarged  tonsils  and  adenoids, 
fresh  air,  and  change  to  a  dry  climate,  if  possible,  are  our  best  means 
of  treatment.  In  addition,  general  supporting  treatment  is  to  be 
advised  (see  The  Management  of  Delicate  Children).  Creosote 
in  small  doses,  i  to  3  minims  after  meals,  for  a  child  from  two  to 
five  years  of  age,  has  seemed  to  me  to  be  of  service  with  some  of 
these  children.  My  greatest  success,  however,  with  these  cases 
has  been  achieved  by  ignoring  the  bronchitis  temporarily  and  put- 
ting the  child  in  the  best  hygienic  surroundings.  Outdoor  life  inland 
and  a  nutritious  diet  are  far  better  than  drugs.  In  many  of  these 
cases,  under  such  a  regime,  the  disease  for  which  the  child  was  brought 
for  treatment  entirely  disappeared  without  any  specific  medication 
whatever,  showing  that  the  bronchial  catarrh  was  nothing  more  or 
less  than  a  manifestation  of  a  greatly  reduced  vitality. 

RECURRENT  BRONCHITIS 

Recurrent  bronchitis  without  the  association  of  asthma  is  oc- 
casionally encountered.  A  case  of  this  kind  was  seen  by  me  five 
months  ago  which  was  so  typical  that  I  will  give  a  brief  history 
of  it  as  taken  from  my  records: 

Illustrative  Case. — A  plump,  well-nourished,  four-year-old  girl 
was  brought  with  a  history  of  attacks  of  bronchitis  lasting  from 
five  to  seven  days  at  intervals  of  not  longer  than  three  wrecks. 
The  physical  examination  was  negative.  The  attacks  com- 
menced when  she  was  two  years  of  age  and  had  continued  for 
two  years.  There  never  was  a  temperature  of  over  100°  F.  with 
the  attacks  and  the  child  was  not  physically  ill.  There  had  never 
been  cyclic  vomiting,  tonsillitis,  or  rheumatism.  The  father  was 
a  sufferer  from  chronic  rheumatism.  The  patient  was  given  a 
diet  suitable  for  her  age  (page  128),  meat  being  allowed  every  sec- 
ond day.  She  was  taking  considerable  sugar,  which  was  greatly 
reduced,  only  enough  being  allowed  to  make  the  food  palatable. 
She  was  given  the  following  prescription: 

I^.     Sodii  salicylatis  (wintergreen) gr.  xxxvj 

Sodii  bicarbonatis gr.  Ixxij 

Elixiris  simplicis ov 

Aquae q.  s.  ad  gij 

M.     Sig. — One  teaspoonful  twice  daily  after  meals. 


262  DISEASES   OF   THE    RESPIRATORY   TRACT 

The  above  prescription  was  given  for  five  days,  followed  by 
an  interval  of  five  days'  rest.  This  procedure  has  now  been  con- 
tinued for  five  months,  during  which  time  there  has  been  no  bron- 
chitis. This  period  includes  the  spring  and  one  summer  month, 
but  as  the  attacks  had  occurred  during  the  previous  summer  as 
frequently  as  during  the  winter,  the  season  of  the  year  cannot  be 
considered  an  element  in  the  relief  of  the  patient.  As  when  a  child 
develops  joint  or  bone  disease,  the  family  can  usually  recall  an 
injury  or  fall  of  some  sort  to  account  for  the  trouble,  so  also,  in  the 
event  of  bronchitis,  an  exposure,  a  change  of  clothing,  or  a  change 
in  the  weather  will  usually  be  regarded  as  a  cause  of  the  attack. 

In  the  case  above  cited,  and  in  others  also,  such  factors  evidently 
have  had  very  little,  if  anything,  to  do  with  the  bronchitis,  for  under 
the  same  climatic  conditions  the  attacks  have  ceased  when  atten- 
tion was  given  to  the  constitutional  condition,  and  proper  diet  and 
medication  prescribed.  The  patients  are  usually  of  gouty  or  rheu- 
matic ancestry.  Some  of  them  have  had  growing  pains,  and  others 
chorea. 

General  Management. — The  management  of  these  cases  is  as  fol- 
lows :  The  child  should  lead  an  active  outdoor  life  when  climatic  con- 
ditions allow.  There  should  always  be  communication  between  the 
sleeping-room  and  the  outer  air.  Red  meats,  including  beef,  mutton, 
and  lamb,  are  given  only  every  second  or  third  day.  Sugar  is  allowed 
only  in  sufficient  amount  to  make  the  food  palatable.  If  the  case 
resists  treatment,  sugar  is  discontinued  and  saccharin  is  substituted. 
Skimmed  milk  is  given  as  a  drink,  eight  ounces  being  allowed  both  for 
breakfast  and  supper.  Fruits,  green  vegetables,  and  cereals  well 
cooked  and  suitable  for  the  age  are  given  freely.  There  must  be  a 
free  evacuation  of  the  bowels  daily.  If  there  is  a  tendency  to  consti- 
pation, the  oil  treatment  (page  174)  is  prescribed.  These  patients 
are  not  influenced  by  the  usual  treatment  for  bronchitis,  so  that 
expectorant  drugs  may  be  omitted.  Large  doses  of  bicarbonate 
of  soda  do  more  toward  shortening  the  attack  than  does  any  other 
form  of  medication.  For  a  child  five  years  of  age,  five  grains  should 
be  given  at  two-hour  intervals.  The  interval  treatment  with  diet 
must  be  relied  upon  to  prevent  a  recurrence  of  the  attacks.  Sali- 
cylate of  soda  (wintergreen)  is  given  for  five  days,  in  doses  of  from 
three  to  five  grains,  well  diluted,  after  meals.  The  salicylate  is 
then  discontinued  and  the  bicarbonate  is  given  for  five  days  in  the 
same  dosage,  when  the  salicylate  is  resumed.  In  this  way,  by 
alternating  the  two  drugs  or  by  giving  aspirin  when  the  salicylate 
disagrees,  the  treatment  is  continued  for  months.  As  the  case 
improves,  an  interval  of  rest  from  all  medication  is  instituted.  If 
it  is  more  convenient,  the  salicylate  and  the  bicarbonate  of  soda 
may  be  given  at  the  same  time.  The  skin  in  these  cases  should  be 
kept  active ;  once  daily  the  child  should  be  given  a  tub-bath  in  luke- 


BRONCHIAL   ASTHMA  263 

warm  water.  After  the  bath,  a  cool  spray  or  spinal  douche  is  used, 
the  temperature  of  the  water  ranging  from  50°  to  70°  F.  An  ex- 
cessive degree  of  cold  is  not  advisable;  it  should  be  sufficient, 
however,  to  insure  good  reaction  after  a  brisk  rubbing  with  a  rough 
towel. 

BRONCHIAL  ASTHMA 

By  bronchial  asthma  in  children  we  understand  a  condition 
characterized  by  recurrent  attacks  of  bronchial  spasm  of  widely 
varying  degrees  of  intensity  and  duration,  toxic  or  reflex  in  origin, 
associated  either  with  an  involvement  of  the  nasopharynx  or  the 
bronchial  mucous  membrane  in  the  form  of  turgescence  or  inflam- 
mation. I  have  come  to  divide  my  cases  of  asthmatic  children 
into  two  classes.  To  the  first  class  belong  comparatiyely  few: 
those  in  whom  paroxysms  are  produced  by  direct  irritation,  as 
by  the  pollen  of  plants  or  the  odors  of  animals  or  flowers,  which 
produce  what  is  known  as  "hay-fever  "  and  the  associated  asth- 
matic condition.  Hay-fever  is  rarely  seen  in  children  under  five 
years  of  age.  In  by  far  the  greater  number  of  my  patients,  which 
constitute  the  second  class,  who  have  suffered  from  asthma  there  could 
be  discovered  the  so-called  "  lithemic  diathesis";  in  other  words, 
there  was  a  gouty  or  rheumatic  association.  Among  these,  cases  of 
recurrent  bronchitis  (page  261)  and  asthma  are  included.  In  not 
a  few  cases  of  recurrent  bronchitis  there  is  asthma  of  such  a  slight 
degree  that  it  may  escape  observation.  In  others  it  is  entirely 
absent.  Repeated  acute  attacks  of  asthma  give  rise  to  pulmonary 
emphysema  which  emphasizes  the  necessity  of  early  medical  treat- 
ment. I  have  two  patients  under  m.y  care,  both  under  ten  years 
of  age,  who  are  hopeless  invalids  because  of  marked  emphysema 
due  to  repeated  attacks  of  asthmatic  bronchitis.  Both  cases  were 
neglected  in  their  early  management.  In  the  Hthemic  type  the 
attacks  sometimes  occur  with  such  regularity  as  to  suggest  the 
"explosion  "  seen  in  cyclic  vomiting.  Enlarged  tonsils  and  adenoids 
may  exist  as  accessory  exciting  causes.  Otherwise  they  cannot  be 
looked  upon  as  etiologic  factors. 

Illustrative  Case. — A  girl  eight  years  of  age  was  brought  to 
me  three  years  ago  with  the  history  of  an  attack  of  asthmatic 
bronchitis  everv  month  for  several  years.  The  asthma  was  not 
severe.  It  was  present  at  the  onset  of  the  attack  and  lasted 
perhaps  for  twenty-four  hours.  The  bronchitis  usually  cleared  up 
in  about  five  days.  She  had  spent  but  little  time  in  New 
York  because  of  her  so-called  frequent  "colds."  Her  mother 
brought  the  child  to  me  in  view  of  a  contemplated  change  of  resi- 
dence. In  Florida  and  Lower  California,  where  she  had  passed  the 
winter,  the  attacks  had  occurred,  but  were  mild  in  character.  As 
soon  as  she  returned  home  the  attacks  returned,  keeping  her  from 


264  DISEASES    OF   THE    RESPIRATORY   TRACT 

school  for  one  week  out  of  every  four  or  five.  In  taking  the  per- 
sonal history,  the  matter  of  adenoids  and  tonsils  was  mentioned, 
when  the  mother  hastened  to  inform  me  that  the  adenoids  and  tonsils 
had  been  removed  twice,  thus  demonstrating  that  they  were  not  a 
factor  in  the  case.  The  child  had  never  suffered  from  rheumatism 
or  cyclic  vomiting.  Aside  from  revealing  a  mild  secondary  anemia 
and  slight  emphysema  the  physical  examination  proved  negative. 
As  to  her  family  history,  I  learned  that  all  of  the  child's  antecedents 
on  both  sides,  for  three  generations,  had  suffered  either  from  rheu- 
matism or  gout.  Her  mother  had  been  a  lifelong  sufferer  from  rheu- 
matism. Upon  close  questioning  as  to  the  child's  diet,  it  was  found 
that  it  consisted  of  red  meat  twice  daily;  she  "hated  "  vegetables, 
took  cereals  only  when  "loaded  "  with  sugar,  and  drank  milk  only 
when  two  teaspoonfuls  of  sugar  were  added  to  each  glass.  She 
had  candy  and  cake  ad  libitum.  She  was  recovering  from  an  attack 
of  bronchitis  when  I  saw  her,  and  was  taking  an  expectorant  cough- 
syrup.  This  was  discontinued,  red  meat  was  permitted  but  twice 
a  week,  the  sugar  was  largely  reduced,  saccharin  being  used  in  the 
milk  to  satisfy  the  abnormal  craving  for  sweets.  She  was  bribed 
by  the  mother  to  eat  green  vegetables  and  cereals.  The  desserts 
consisted  largely  of  stewed  fruits  flavored  with  saccharin.  Candy, 
cake,  and  pastry  were  forbidden.  She  was  given  four  grains  of  the 
salicylate  of  soda  (wintergreen)  three  times  daily  for  five  days, 
which  was  followed  by  ten  grains  of  the  bicarbonate  three  times  daily 
for  five  days.  This  treatment  was  continued  for  six  months,  during 
which  time  the  salicylate  was  given  for  five  days,  the  bicarbonate 
for  five  days,  and  no  medication  whatever  for  five  days,  when  the 
procedure  was  repeated.  During  the  following  six  months  the 
salicylate  and  the  bicarbonate  of  soda  were  given  but  ten  days  out 
of  each  month,  and  during  the  entire  year  but  one  mild  attack  of 
bronchial  asthma  occurred. 

Treatment. — The  management  of  bronchial  asthma  consists  of 
care  during  the  attack,  and  the  interval  treatment,  the  latter  being 
by  far  the  most  important.  In  infants  and  young  "  runabouts  "  with 
this  type  of  trouble,  there  is  usually  considerable  bronchitis,  and  this 
requires  our  attention.  I  have  found,  in  addition  to  the  usual 
laxatives,  calomel  or  castor  oil,  that  a  combination  of  syrup  of 
ipecac,  antipyrin,  and  bromid  of  soda  gives  the  most  prompt  results 
as  far  as  internal  medication  is  concerned.  For  a  child  six  months 
of  age  the  following  prescription  has  been  found  useful : 

I^.     Syrupi  ipecacuanhae gtt.  xviij 

Antipyrina? gr.  vj 

Sodii  bromidi gr.  xviij 

Syrupi  rubi  idaei 5  v 

Aquae q.  s.  ad  o  ij 

M.  ft.     Sig. — One    dram    every    two    hours — six   doses    in    twenty-four 
hours. 


BRONCHIAL   ASTHMA  265 

For  one  year  of  age: 

1}.     Syrupi  ipecacuanhas gtt.  xxiv 

Antipyrinse gr.  xij 

Sodii  bromidi gr.  xxiv 

Syrupi  rubi  idaei 5v 

Aquae q.  s.  ad  5ij 

M.  ft.     Sig. — One     teaspoonful    at    two-hour     intervals — six     doses     in 
twenty-four  hours. 

For  a  child  from  two  to  three  years  of  age: 

J^.     Syrupi  ipecacuanha? gtt.  xxxvj 

Antipyrinae gr.  xviij 

Sodii  bromidi gr.  xxxvj 

Syrupi  rubi  idaei ov 

Aquae q.  s.  ad  5ij 

M.  ft.     Sig. — One  teaspoonful  in  water,  at  two-hour  intervals — six  doses 
in  twenty-four  hours. 

In  addition  to  the  internal  medication,  the  child  will  often  be 
greatly  relieved  by  stimulant  inhalations  as  described  under  Spas- 
modic Croup  (page  249).  If  the  condition  is  urgent,  the  inhalations 
may  be  given  for  thirty  minutes  with  thirty  minutes'  rest.  Mus- 
tard in  the  proportion  of  one  part  of  mustard  to  two  parts  of  flour 
(page  259),  so  applied  as  to  envelop  the  entire  thorax,  will  often 
relieve  the  spasm  sufficiently  to  reduce  the  respirations  from  ten 
to  twenty  a  minute.  The  mustard  should  remain  on  long  enough 
to  redden  the  skin  and  should  not  be  repeated  oftener  than  once 
in  four  hours.  The  cold-air  treatment  in  bronchial  asthma  is  con- 
traindicated,  regardless  of  the  age  of  the  patient.  Warm  moist 
air  at  from  68°  F.  to  70°  F.  is  best.  A  sudden  blast  of  cold  air  may 
be  sufficient  to  increase  the  severity  of  the  paroxysms  to  a  marked 
degree.  Ventilation,  however,  is  a  necessity  in  these  cases.  The 
best  means  of  obtaining  it  is  by  the  use  of  two  rooms,  one  of  which 
may  be  aired  while  the  other  is  occupied.  Before  the  child  is  changed 
to  the  aired  room,  its  temperature  should  be  raised  to  that  of  the 
other. 

In  older  children  after  the  fifth  year  the  bronchial  spasm  may 
be  considerable,  and  more  active  measures  may  be  required  to  fur- 
nish temporary  relief.  Here  the  methods  usually  employed  for 
the  same  purpose  in  adults  may  be  brought  into  use.  A  few  whiffs 
of  chloroform  will  often  be  effective.  Fumes  of  nitrate  of  potash 
paper  will  sometimes  be  of  service.  At  this  age,  also,  a  combination 
of  antipyrin  and  bromid  of  soda  may  be  brought  into  use.  For  a  child 
from  five  to  ten  years  of  age,  three  grains  of  antipyrin  with  from 
six  to  ten  grains  of  bromid  of  soda,  repeated  in  two  hours,  will  often 
be  followed  by  a  cessation  of  the  paroxysm.  As  soon  as  the  spasm 
subsides  the  sedatives  should  be  discontinued.  I  have  never  found 
it  necessary  to  give  morphin  hypodermatically  or  otherwise  in  these 
cases.  In  a  very  severe  case,  in  a  girl  eight  years  of  age,  a  com- 
bination   of  antipyrin  and  codein  in  full  dosage  was  required  to 


266  DISEASES    OF    the;    RESPIRATORY   TRACT 

control  the  paroxysms.  She  was  given  one-fourth  grain  of  codein 
and  four  grains  of  antipyrin  at  two-hour  intervals  until  three  doses 
had  been  given. 

The  interval  treatment  for  the  bottle-fed  consists  in  a  reduction 
of  the  sugar  to  one-half  the  amount  suitable  for  the  age  and  the 
use  of  one  grain  of  bicarbonate  of  soda  for  each  ounce  of  the  milk 
food  given.  The  bowels  must  be  kept  properly  open,  although 
constipation  or  intestinal  toxemia  has  never  appeared  to  me  to  be 
an  important  factor  in  asthmatic  children.  The  interval  treat- 
ment for  older  children  is  most  important,  for  by  it  we  are  able  to 
postpone  the  attacks.  These  cases,  as  I  have  indicated,  are  usually 
in  lithemic  subjects,  and  the  scheme  of  management  followed  out 
is  the  same  as  for  rheumatism,  chorea,  recurrent  bronchitis,  and 
cyclic  vomiting.  Sugar  is  reduced  to  a  minimum,  red  meat  is  given 
not  oftener  than  every  second  day,  and  then  only  in  moderate 
amounts.  The  child's  proteid  nutrition  is  maintained  by  the  use 
of  a  high-proteid  cereal,  such  as  oatmeal,  and  purees  of  dried  peas, 
beans,  and  lentils.  The  eating  of  green  vegetables  is  encouraged. 
Food  between  meals  is  forbidden.  Fruits  are  used  in  moderation 
and  an  active  outdoor  life  is  encouraged.  At  bedtime  the  child 
is  given  a  brine  bath  (page  31),  followed  by  a  vigorous  dry  rub. 
The  mother  or  attendant  is  instructed  that  one  bowel  evacuation 
daily  must  be  insured.  The  medication  consists  of  bicarbonate 
of  soda,  from  five  to  ten  grains  a  day  for  five  days,  alternating 
with  the  salicylate  of  soda  (wintergreen)  in  doses  of  from  three  to 
five  grains  three  times  a  day.  This  is  continued  for  a  month  or 
two  until  its  effect  on  a  recurrence  is  noted.  If  the  salicylate  of 
soda  disturbs  the  digestion,  the  same  quantity  of  aspirin  may  be 
given.  The  further  continuation  of  the  medication  depends  upon 
the  effect  produced.  Usually  in  two  months  the  salicylate  may 
be  given  in  smaller  doses.  Interrupted  medication,  however,  should 
be  continued  for  several  months.  When  my  cases  with  a  bad  family 
history  have  been  relieved,  I  continue  the  diet  permanently,  giving 
the  medication  for  but  five  or  ten  days  and  then  omitting  it  for 
sixty  or  eighty  days,  when  it  is  again  given  for  a  short  time,  con- 
tinuing thus  for  as  long  as  may  be  thought  best  in  the  individual 
case. 

BRONCHOPNEUMONIA;  CATARRHAL  PNEUMONIA 
Catarrhal  pneumonia,  on  account  of  its  large  mortality,  and 
because  of  its  frequent  appearance  as  a  complication  of  almost 
every  disease  of  infancy,  is  one  of  the  most  formidable  ailments 
which  we  are  called  upon  to  treat.  The  disease  is  usually  described 
as  primary  or  secondary.  Among  the  several  hundred  cases  which 
have  come  under  my  observation  comparatively  few — less  than 
5    percent — were    primary.     Those    described    as    primary    usually 


bronchopneumonia;    catarrhal  pneumonia  267 

follow  a  bronchitis,  often  a  neglected  bronchitis.  The  disease 
varies  considerably  as  regards  its  severity,  depending  on  the  age 
and  condition  of  the  child,  the  nature  of  the  infection,  and  the  amount 
of  lung  involved.  It  is  most  fatal  when  associated  with  diphtheria 
or  measles. 

Catarrhal  pneumonia  demands  our  most  careful  attention, 
not  only  on  account  of  the  delicate  organs  attacked,  enclosed  in 
weak  thoracic  walls,  but  because — unlike  lobar  pneumonia,  scarlet 
fever,  typhoid  fever,  and  many  other  diseases  of  early  Ufe — it  has 
no  self -limitation,  no  cycle.  While  in  the  other  diseases  mentioned 
we  are  required  only  to  assist  a  patient  through  the  various  stages, 
in  catarrhal  pneumonia  we  must  do  more,  for  here  a  cure  is  demanded. 

Treatment. — Every  child  at  the  commencement  of  an  illness  has  a 
definite  resistance  to  it.  In  catarrhal  pneumonia,  for  the  reasons  just 
given,  it.  must  be  our  effort  to  preserve  every  strength  unit  which 
the  child  possesses.  An  immense  amount  of  vitality  is  wasted  in  sick 
children  because  of  irritability,  restlessness,  and  loss  of  sleep.  One 
of  the  first  duties  in  a  given  case  is  not  to  give  this  or  that  drug, 
or  use  this  or  that  local  application,  but  to  make  the  child  com- 
fortable— to  put  him  in  the  best  position  to  withstand  disease. 
We  must  establish  a  sick-room  regime  which  will  make  this  possible. 

The  Sick-room. — The  value  of  a  constant  supply  of  fresh  air  is 
too  little  appreciated.  In  every  case  there  should  be  a  direct  com- 
munication between  the  sick-room  and  the  open  air,  throughout  the 
attack.  Various  means  of  ventilation  have  been  devised,  of  which 
the  window-board  (page  43)  is  the  most  effective,  as  it  separates 
the  sash  and  allows  the  free  entrance  of  a  current  of  air  which  is 
directed  upward.  If  plenty  of  fresh  air  at  a  proper  temperature 
were  available  during  the  early  part  of  the  illness,  there  would  be 
much  less  use  for  tanks  of  oxygen  later. 

An  absolute  necessity  in  a  sick-room  is  a  good  thermometer. 
In  pneumonia  cases  it  should  never  register  above  70°  F.  There 
is  marked  tendency  to  coddle,  to  wrap,  to  overclothe,  pneumonia 
patients.  The  patient  requires,  even  during  the  winter,  absolutely 
nothing  more  than  a  medium- weight  flannel  shirt,  a  band,  if  one 
is  ordinarily  worn,  and  the  usual  night-dress.  Some  years  since  I 
discarded  the  oiled  silk  jacket.  It  is  cumbersome,  it  is  impossible 
to  keep  clean,  and  it  overheats  the  patient.  Given  an  infant  with 
catarrhal  pneumonia,  have  him  heavily  clad,  keep  him  in  an  unven- 
tilated,  overheated  room,  in  close  contact  with  an  adult  body,  and 
you  have  a  patient  who  is  tremendously  handicapped.  There  is 
but  one  place  for  a  sick  infant,  and  that  is  in  his  own  roomy  crib. 

Diet. — In  every  illness  with  fever,  the  digestive  capacity  is  con- 
siderably reduced.  If  the  usual  milk  diet  is  continued,  we  are  very 
liable  to  have  a  gastro-enteric  infection  added,  oftentimes  as  a  serious 
complication,   to  the  existing  disease.     In  the  breast-fed  a  drink 


268  DISEASES   OF    THE    RESPIRATORY   TRACT 

of  water  is  ordered  for  the  child  before  the  nursings  and  between 
them.  The  nursing  hours  should  be  the  same  as  in  health,  but  the 
time  allowed  for  each  nursing  should  be  reduced  from  one-third  to 
one-half.  In  the  bottle-fed  the  milk  strength  should  be  reduced 
from  one-third  to  one-half  by  dilution  with  water,  the  quantity  re- 
maining the  same.  Children  from  two  to  four  years  of  age  are  put 
on  a  diet  of  diluted  milk,  gruels,  and  broths. 

Bowels. — Normal  bowel  function  is  more  necessary  for  the  sick 
than  for  the  well.  There  should  be  at  least  one  stool  in  twenty-four 
hours. 

General  Treatment. — Having  placed  the  child  under  the  best 
dietetic  and  hygienic  conditions,  we  are  in  a  position  to  use  medi- 
cation to  a  much  better  advantage.  But  in  its  use,  and  in  perform- 
ing the  various  offices  for  the  patient,  it  must  be  our  effort  to  disturb 
him  as  little  as  possible.  In  our  anxiety  to  do,  we  are  very  liable  to 
overdo,  with  disastrous  results.  If  a  well  child  were  given  syrup  ex- 
pectorants, stimulants,  baths,  and  local  applications,  something  being 
done  for  him  every  hour  or  two  in  the  twenty-four,  he  would  have 
to  be  a  strong  child  to  withstand  the  treatment.  We  should  treat 
our  ill  with  still  greater  consideration.  Make  the  intervals  between 
which  the  child  is  to  be  disturbed  at  night  as  long  as  possible  by 
giving  food,  medicine,  and  local  treatment  at  one  time.  When 
possible,  I  always  endeavor  to  make  the  interval  at  least  three  hours. 

Steam  Inhalations. — Among  the  distinctly  remedial  measures, 
aside  from  those  administered  internally,  steam  inhalations  with  creo- 
sote deserve  an  important  place.  The  patient  is  placed  in  its  crib, 
which  is  covered  and  draped  with  sheets  so  as  to  make  a  fairly  tight 
enclosed  space.  The  apparatus  necessary  is  an  ordinary  croup  kettle 
(see  page  248).  Ten  drops  of  creosote  are  added  to  one  quart  of 
water  and  placed  in  the  kettle.  The  nozzle  of  the  kettle  is  intro- 
duced between  the  sheets  at  a  safe  distance  from  the  child's  face 
and  hands,  the  steaming  being  carried  on  for  thirty  minutes  every 
three  hours.  The  sheets  should  be  parted  shghtly  about  every  ten 
minutes,  to  allow  a  renewal  of  the  air.  The  inhalations  are  to  be 
given  whether  the  patient  is  sleeping  or  waking.  As  he  improves, 
they  may  be  given  less  frequently  until  normal  respirations  and  the 
chest  signs  tell  us  they  are  no  longer  required. 

Counter-irritants. — The  application  of  counter-irritants  to  the  skin 
over  the  thorax  is,  to  my  mind,  of  great  service  in  cases  in  which  there 
is  much  bronchial  catarrh,  which  includes,  of  course,  most  cases.  In 
order  that  a  counter-irritant  may  be  of  service,  a  distinct  red  blush 
must  be  produced  on  the  skin.  Turpentine  diluted  with  oil, — one- 
third  turpentine  and  two-thirds  oil, — when  briskly  rubbed  on  the  parts 
for  a  few  minutes,  produces  a  fairly  satisfactory  counter-irritation. 
The  old-fashioned  home-made  mustard  plaster  has  served  me  well 
as  a  counter-irritant.     Written  directions  should  always  be  given 


bronchopneumonia;    catarrhal  pneumonia  269 

for  the  preparation  of  the  plaster,  and  the  boundaries  of  the  area  of 
the  skin  to  be  covered  should  be  outlined  with  a  pencil  on  the 
skin's  surface.  If  the  nurse  or  mother  is  told  merely  to  put  a  mus- 
tard plaster  on  the  chest,  a  plaster  the  size  of  a  man's  hand  will 
usually  be  placed  somewhere  between  the  umbilicus  and  the  chin! 
For  the  first  two  or  three  applications  one  part  of  mustard  to  two 
parts  of  flour  is  used.  This  is  moistened  with  hot  water  and  made 
of  the  consistency  of  a  rather  thin  paste,  which  is  then  spread  upon 
cheese-cloth,  old  muslin,  or  linen,  cut  to  the  desired  size.  The  plas- 
ter is  readily  held  in  position  by  a  bandage  of  any  thin  material 
extending  around  the  chest.  When  the  skin  is  well  reddened, 
usually  within  from  five  to  fifteen  minutes,  the  plaster  is  removed 
and  vaselin  or  sweet  oil  applied.  I  never  use  a  plaster  oftener 
than  once  in  six  hours,  and  then  only  in  the  severest  cases.  Ordi- 
narily, two  or  three  applications  in  twenty-four  hours  are  sufficient. 
If  the  plasters  are  continued  for  several  days,  in  order  to  avoid 
blistering,  it  will  be  necessary  to  make  them  much  weaker  after  a 
day  or  two — one  part  of  mustard  to  five  or  ten  of  flour.  Counter- 
irritation  is  particularly  effective  when  used  at  the  commencement 
of  an  attack. 

Mustard  Baths. — In  cases  of  sudden  onset,  wdth  high  fever,  rapid 
breathing,  and  cold  extremities,  a  mustard  bath — one  tablespoonful 
of  mustard  to  six  gallons  of  water  at  100°  F. — will  often  furnish 
marked  relief  to  the  immediate  symptoms.  Autopsies  on  these  cases 
show  a  general  congestion  of  the  internal  organs,  wdth  intense  con- 
gestion of  the  lungs.  The  bath  may  be  repeated  at  six-hour  inter- 
vals. This  type  of  case  is  usually  very  rapid  in  its  development,  the 
child  being  relieved  or  dead  in  from  thirty-six  to  forty-eight  hours. 
By  "relieved  "  we  do  not  mean  that  the  child  has  recovered,  but 
that  the  acute  urgent  symptoms  have  subsided.  In  my  opinion 
only  these  cases  should  be  considered  primary. 

Drugs. — The  internal  medication  is,  to  a  large  extent,  sympto- 
matic. In  any  disease  a  great  deal  of  harm  may  be  done  to  young 
children  by  the  thoughtless  use  of  drugs.  In  catarrhal  pneumonia  it 
is  particularly  necessary  that,  in  our  endeavors  to  assist  the  patient, 
we  do  nothing  to  harm  him,  for  we  are  treating  a  disease  in  which 
his  powers  of  resistance  count  for  everything.  In  young  children, 
even  in  health,  the  digestive  functions  are  very  easily  disordered. 
In  illness  with  fever,  with  the  accompanying  nervous  exhaustion, 
the  stomach  is  most  easily  disturbed,  the  child  is  not  properly  nour- 
ished, and  his  powers  of  resistance  are  markedly  diminished. 

Expectorants  must  be  given  with  care  and  are  better  prescribed 
in  the  form  of  tablets  or  powders.  The  use  of  heavy  syrups  of 
wild  cherry,  tolu,  etc.,  with  large  doses  of  the  ammonium  salts, 
only  adds  to  the  burden  of  the  patient.  For  a  child  one  year 
of  age  with  catarrhal  pneumonia,  y^o  grain  of   tartar  emetic  and 


270  DISEASES   OF  THE   RESPIRATORY  TRACT 

4V  grain  of  ipecac  answer  well  as  an  expectorant.  If  the  cough  is 
very  severe  and  persistent,  |  grain  of  Dover's  powder  in  tablet  form 
with  sugar  of  milk  dissolved  in  at  least  two  teaspoonfuls  of  water, 
may  be  given,  preferably  after  feeding,  not  oftener  than  once  in 
two  hours.  The  ammonium  salts  so  generally  used  in  catarrhal 
pneumonia  as  routine  treatment  are  badly  borne  by  the  stomach. 
The  muriate  of  ammonia  is  of  some  value  during  resolution,  but 
to  a  child  two  years  old. it  should  not  be  given  in  larger  doses  than 
^  grain  well  diluted,  at  two-hour  intervals;  personally,  however, 
I  rarely  use  it.  With  high  fever  and  great  restlessness,  which  are 
not  affected  by  sponging,  and  where  for  any  reason  rational  bath- 
ing is  impossible,  a  combination  of  caffein,  Dover's  powder,  and 
phenacetin  may  be  used.  For  a  child  one  year  of  age  I  would  give 
i  grain  of  caffein,  ^  grain  of  Dover's  powder,  and  i^  grains  of  phen- 
acetin at  about  four-hour  intervals.  In  giving  Dover's  powder  it 
is  well  to  watch  the  bowels,  as  constipation  often  follows  its  use. 

Heart  stimulants  are  usually  necessary,  and  in  their  selection 
two  points  are  to  be  considered — their  effect  on  the  heart  and  their 
effect  on  the  stomach.  But,  first,  what  are  the  indications  for  the 
use  of  a  heart  stimulant?  Ordinarily,  I  think,  they  are  used  too 
early.  A  heart  stimulant  should  never  be  given  simply  because 
a  child  has  pneumonia  or  diphtheria  or  scarlet  fever,  but  it  should 
be  given  in  pneumonia  or  diphtheria  or  scarlet  fever  as  soon  as 
the  heart  needs  assistance.  And,  briefly,  there  are  two  conditions 
to  guide  us,  a  very  rapid  pulse  or  a  soft,  usually  not  rapid,  pulse 
with  a  tendency  to  irregularity.  In  a  general  way,  I  believe  that  a 
heart  which  is  beating  at  the  rate  of  1 50  a  ininute  during  quiet  or  sleep, 
and  which  is  not  strengthened  by  sponging  or  packs,  needs  assistance, 
and  the  drug  which  has  served  me  best  is  tincture  of  strophanthus, 
which  acts  as  a  direct  stimulant  to  the  heart  muscle.  The  pulse, 
by  its  use,  is  made  stronger,  fuller,  and  less  rapid.  When  the  heart's 
action  shows  a  tendency  to  irregularity,  with  a  soft,  easily  com- 
pressible pulse,  then  strychnin  is  the  remedy.  For  a  child  one 
year  of  age  one  drop  of  strophanthus  in  water  may  be  given  every 
three  hours,  or  -3^0  grain  of  strychnin  every  three  hours,  to  be  in- 
creased to  Yoo^  or  even  to  y^^  grain  every  three  hours  for  a  few 
doses  if  the  case  is  carefully  watched  for  symptoms  of  strychnin 
poisoning.  Strophanthus  and  strychnin  possess  advantages  over 
all  other  stimulants  in  that  they  do  their  work  and  have  no  un- 
pleasant effect  on  the  stomach,  as  is  the  case  with  alcohol,  digitalis, 
and  the  ammonium  preparations.  If  the  condition  is  very  urgent, 
strophanthus  and  strychnin  may  be  used  in  combination.  Digi- 
talis I  rarely  employ  because  of  its  tendency  to  interfere  with  diges- 
tion. Alcohol  in  the  form  of  whisky  or  brandy  is  very  rarely  of 
great  service  in  catarrhal  pneumonia.  It  may  stimulate  the  heart, 
but  its  prolonged  use  greatly  upsets  the  stomach.     It  should  be 


bronchopneumonia;    catarrhal  pneumonia  271 

withheld  until  late  in  the  disease,  when  other  means  of  stimulation 
fail.  Then,  given  in  large  amounts,  it  may  be  the  means  of  saving 
the  patient.  One-half  dram  of  whisky  or  brandy,  well  diluted, 
may  be  given  every  hour  or  every  two  hours  to  a  child  one  year 
of  age.  However,  the  cases  of  catarrhal  pneumonia  actually  saved 
by  the  use  of  alcohol  are  few  indeed.  One  one-hundredth  grain  of 
nitroglycerin  every  three  hours  for  a  child  one  year  of  age  is  of  service 
in  cases  where  there  is  marked  cyanosis  with  cold  extremities.  Its 
use  should  be  discontinued  as  soon  as  improvement  in  this  respect 
is  noticed.  The  one  unpleasant  effect  that  I  have  observed  from 
its  administration  is  its  tendency  to  produce  headache  and  marked 
restlessness. 

Baths. — A  sponge-bath  at  95°  F.  for  cleansing  purposes  may  be 
given  daily. 

What  is  to  be  our  guide  in  dealing  with  the  temperature?  At 
what  degree  of  temperature  are  we  to  interfere,  the  rectal  temper- 
ature alone  being  considered?  This  depends  to  a  great  extent 
upon  what  is  behind  the  fever  and  the  effect  of  the  fever  upon  the 
individual  patient.  If  a  child  has  a  high  fever  and  is  more  com- 
fortable when  it  is  reduced, — if  he  will  digest  his  food  better  and 
sleep  better, — it  is  our  duty  to  reduce  it.  Further,  by  reducing 
the  temperature  we  lessen  the  work  of  the  heart,  saving  it  often- 
times many  beats  a  minute.  Usually  when  the  temperature  has 
a  tendency  to  run  above  104°  F.,  interference  is  of  advantage,  and 
the  best  means  at  our  command  is  the  use  of  local  applications  of 
water  in  the  form  of  sponge-baths  or  packs.  If  the  temperature 
is  easily  controlled,  a  sponge-bath  will  answer  our  purpose.  Either 
salt  or  alcohol  may  be  added  to  the  water.  Ordinarily  two  teaspoon- 
fuls  of  salt  to  a  quart  of  water,  or  one  part  alcohol  to  three  parts 
water,  is  ample.  Cold  water  thus  used  serves  two  purposes — it 
acts  as  a  sedative  and  it  reduces  the  fever.  Cold  sponging,  while 
not  controlling  the  fever  as  effectually  as  does  a  bath  or  a  pack, 
possesses  the  advantage  that  the  most  unskilled  can  use  it.  For 
sponging,  the  child  should  be  stripped  and  covered  with  a  flannel 
blanket,  the  sponging  being  done  under  the  blanket.  In  order 
not  to  antagonize  or  frighten  the  child,  it  is  best  to  begin  with  the 
water  at  95°  F.  and  gradually  to  reduce  it  to  70°  or  75°  F.  by  the 
addition  of  ice  or  cold  water.  The  sponging  may  be  continued  from 
ten  to  twenty  minutes,  and  should  not  be  repeated  at  shorter  intervals 
than  ninety  minutes.  After  the  sponging  is  completed  the  skin 
should  be  rubbed  briskly  for  a  few  minutes  with  a  dry  towel.  If 
the  temperature  is  not  readily  controlled  in  this  way,  it  is  best  to 
use  other  means,  as  too  frequent  sponging  exhausts  the  patient. 
As  a  means  of  controlling  the  temperature  in  children,  the  tub-bath 
has  not  been  successful  in  my  hands,  for  the  reason  that  I  have  not 
been  able  by  this  means  to  control  the  fever.     The  exposure,  the 


272  DISEASES    OF    THE    RESPIRATORY   TRACT 

fright,  and  the  necessary  shortness  of  the  bath  render  it  very  unsatis- 
factory. 

Cold  Pack. — By  far  the  best  means  at  our  command  for  controlUng 
a  continued  high  fever  is  by  the  use  of  the  cold  pack  (page  481). 
Properly  applied,  it  is  without  the  slightest  danger.  It  is  prepared 
as  follows :  A  large  bath-towel  or  any  thick  absorbent  material  may 
be  used,  slits  being  cut  in  one  end  of  the  towel  through  which  the 
arms  may  pass.  The  towel  is  folded  over  the  body,  and  should  extend 
from  the  neck  to  the  middle  of  the  thighs ;  the  arms  and  the  legs  from 
the  knees  down  should  remain  free;  a  hot-water  bag,  carefully 
guarded,  should  be  placed  at  the  feet.  The  towel  is  moistened  with 
water  at  95°  F.  It  is  well  to  make  the  pack  warm  at  first,  so  that  the 
child  will  not  be  frightened,  as  shock  will  thus  be  avoided.  I  have 
known  severe  shock  to  follow  in  a  case  where  a  child  with  a  tempera- 
ture of  105°  F.  was  put  suddenly  into  a  pack  at  70°  F.  In  two  or  three 
minutes  the  towel  is  moistened  with  water  at  85°  F.,  then  at  80°  F. 
When  80°  F.  is  reached,  it  is  best  not  to  make  the  water  any  colder 
for  half  an  hour,  at  which  time  the  temperature  of  the  patient  is 
taken.  If,  in  the  beginning,  it  was  105°  F.  and  then  shows  a  slight 
or  no  reduction,  the  temperature  of  the  pack  may  be  reduced  to 
70°  or  even  to  60°  F.  by  the  addition  of  cold  water  or  ice,  without  re- 
moving the  child,  who  is  turned  from  side  to  side  so  that  all 
parts  of  the  enveloping  towel  may  be  moistened  with  the  cool  water. 
During  the  first  hours  in  the  pack,  the  temperature  should  be  taken 
every  half  hour,  and  when  it  is  reduced  to  102°  F.,  the  child  is  removed 
and  wrapped  in  a  warm  blanket.  In  cases  of  sudden  and  persistent 
high  fever,  the  child  may  be  kept  in  the  pack  continuously.  We 
aim  to  keep  the  temperature  between  102.5°  and  103.5°  F.  The 
degree  of  cold  necessary  to  control  the  fever  in  a  given  case  will  soon 
be  learned.  I  recently  kept  in  a  pack  for  seventy-two  hours  a  four- 
year-old  boy,  ill  with  lobar  pneumonia.  In  this  case  a  pack  at  70°  F. 
was  necessary  to  keep  the  temperature  at  104°  F.  or  slightly  lower. 
A  fresh  towel  should  be  applied  every  three  hours.  An  ice-bag 
should  be  kept  at  the  head,  a  hot-water  bag  at  the  feet,  and  the 
patient  covered  with  a  flannel  blanket  of  medium  weight. 

Oxygen. — Oxygen  is  of  immense  ser\nce  in  very  severe  cases  with 
much  lung  involvement.  It  may  be  given  continuously  for  one  or 
two  minutes  out  of  every  seven  or  ten.  As  often  given,  one  or  two 
minutes  every  half  hour,  it  is  of  little  or  no  service. 

LOBAR  PNEUMONIA 
The  onset  of  lobar  pneumonia  is  usually  sudden.  In  about 
3  percent  of  the  cases  it  is  ushered  in  by  a  convulsion.  In  older 
children,  those  past  the  third  year,  there  may  be  an  initial  chill. 
There  is  almost  always  high  fever  from  the  beginning  of  the  attack. 
The  face  is  flushed,  the  lips  are  separated  and  parched,  and  the 


LOBAR    PNEUMONIA 


273 


child  usually  breathes  through  its  mouth.  The  respiration  is  markedly 
accelerated, — forty  to  sixty  per  minute, — the  end  of  each  inspira- 
tion being  marked  by  a  peculiar  sigh  or  groan.  At  this  time  there 
may  be  in  the  chest  no  discernible  signs  of  the  disease.  The  respir- 
atory murmur  over  the  entire  thorax  is  rendered  harsher  than  nor- 
mal, but  this  is  caused  by  the  rapid  respiration.  Bronchial  breath- 
ing and  bronchial  voice  may  be  delayed  until  the  fourth  or  fifth 
day,  although  they  are  usually  present  within  forty-eight  hours 
from  the  onset  of  the  acute  symptoms.  In  a  case  seen  recently, 
signs  of  consolidation  did  not  appear  until  the  seventh  day  of  the 
disease,  and  on  that  day  the  crisis  occurred.  It  was  objectively 
a  typical  case  of  lobar  pneumonia,  but  without  chest  signs  until 
the  seventh  day.  A  case  of  this  type  is  usually  referred  to  as  a 
"central  "  pneumonia;  the  consolidated  area  being  deep  in  the 
lung  tissue,  and  covered  by  normal  lung,  cannot  be  made  out. 
The  temperature  at  the  onset  will  usually  be  from  103°  to  105°  F. 
In  an  average  case  the  temperature  range  throughout  an  attack 
is  from  103°  to  105°  F. 

Lobar  pneumonia  is  a  distinctly  infectious  disease  terminating, 
in  recovery  cases,  by  crisis.  The  crisis  may  be  looked  for  any  time 
after  the  third  day  of  the  disease,  though  it  seldom  occurs  before 
the  fifth  day,  the  usual  time  being  from  the  fifth  to  the  ninth 
day  of  the  disease.  A  crisis  delayed  beyond  the  ninth  day  means 
a  very  serious  infection  and  a  very  grave  prognosis.  I  have  had 
recovery  cases  in  which  the  crisis  did  not  occur  until  the  eleventh 
day,  one  on  the  thirteenth,  and  one  on  the  fifteenth  day.  In  eight 
fatal  cases  in  the  New  York  Infant  Asylum,  two  died  on  the  eighth 
day,  two  on  the  ninth,  two  on  the  twelfth,  one  on  the  twenty-first, 
and  one  on  the  tvventy-fourth  day  of  the  disease. 

Among  the  out-patient  poor,  lobar  pneumonia  frequentlv  runs 
its  course  unrecognized.  At  the  outdoor  service  of  the  Babies' 
Hospital  we  not  infrequently  have  cases  brought  to  us  with  lobar 
pneumonia  in  the  stage  of  resolution.  The  child  had  a  hacking 
cough  with  fever,  and  was  supposed  to  be  suffering  from  a  cold  or 
an  attack  of  influenza.  There  was  evidently  no  pain,  hence  nothing 
was  suspected.  In  children  localized  pain  in  the  chest  is  often 
absent  throughout  the  entire  attack. 

Lobar  pneumonia  runs  a  limited  course,  with  a  strong  tendency 
to  recovery.  It  is  a  disease  which  children  bear  well,  under  proper 
management — a  disease  for  which  there  is  no  specific  treatment, 
and  our  efforts  in  restoring  the  patient  to  health  are  supportive 
only,  so  that  the  patient  may  be  enabled  successfully  to  withstand 
the  disease. 

Treatment. — When  a  child  is  stricken  with  lobar  pneumonia  we 
know  that  his  physical  strength  is  to  be  severely  tested,  and  our 
first  effort  should  be  to  place  him  in  such  a  position  that  he  may 


274  DISEASES   OF   THE    RESPIRATORY   TRACT 

to  the  best  advantage  cope  with  the  enemy.  In  order  to  do  this, 
every  detail  of  his  daily  life  should  so  be  arranged  as  to  place  all 
the  organs  of  the  body  in  the  most  favorable  position  to  meet  the 
changed  conditions  produced  by  disease.  Telling  the  mother  what 
to  do  for  the  fever  and  writing  a  prescription  for  a  cough  mixture 
is  a  most  careless  way  of  treating  pneumonia;  it  is  the  method 
of  the  prescribing  apothecary;  physicians  never  do  it.  A  proper 
regime  must  be  established  as  soon  as  the  child  becomes  ill.  The 
bowel  function,  the  room-temperature,  ventilation,  and  sleep,  as 
well  as  special  medication,  are  to  be  considered.  The  child  must 
be  kept  as  comfortable  as  the  conditions  allow,  and  his  comfort 
means  the  avoidance  of  everything  causing  restlessness  or  irri- 
tability, which  throws  more  work  upon  the  heart  and  diminishes 
his  resistance  to  the  disease. 

The  Sick-roam. — Being  usually  a  winter  disease,  the  temperature 
of  the  room  and  the  ventilation  demand  special  attention.  The  tem- 
perature of  the  room  should  be  kept  at  70°  F.,  or  very  near  that  figure, 
both  day  and  night.  Wide  fluctuations  in  the  temperature  should 
not  be  allowed.  A  child  with  lobar  pneumonia  needs  the  best  air 
that  can  be  furnished.  A  large  room,  if  at  hand,  should  always  be 
selected,  and  there  must  always  be  a  direct  communication  with 
the  open  air.  A  window-board  (page  43)  is  a  convenient  means 
of  ventilation.  The  child  should  be  kept  in  its  crib,  and  not  held 
on  the  lap  of  the  mother  or  nurse. 

Quiet  should  be  maintained-  in  the  sick-room,  only  those  in 
attendance  upon  the  patient  being  allowed  there.  A  sick-room  is  no 
place  for  visitors  and  otherwise  curious  persons.  Their  presence 
annoys  the  child  and  takes  away  just  so  many  strength  units,  which 
may  determine  the  question  of  life  or  death. 

The  Clothing. — The  clothing  should  be  the  usual  night -clothing. 
I  have  long  since  discarded  the  oiled-silk  jacket  or  any  special  means 
of  covering.  The  oiled-silk  jacket  or  a  jacket  made  of  cotton  wad- 
ding is  very  easy  to  put  on,  but  very  difficult  to  take  off  with  safety; 
further,  it  has  a  tendency  to  elevate  the  temperature  of  the  patient, 
it  makes  him  uncomfortable,  particularly  during  convalescence, 
and  prevents  the  free  action  of  the  skin.  These  objections,  with 
the  fact  that  there  is  no  rational  argument  for  its  use,  are  sufficient 
to  condemn  it. 

The  Bowels. — The  patient's  bowels  should  move  once  or  twice 
daily.  There  should  be  a  standing  order  with  the  nurse  or  mother 
for  an  enema  to  be  given  if  the  bowels  do  not  move  once  in  twenty- 
four  hours.  One-half  to  one  grain  of  calomel  in  doses  of  one-sixth 
of  a  grain  every  hour  is  usually  of  considerable  service.  In  a  case 
in  which  there  is  very  high  fever  I  often  order  the  dose  repeated 
every  three  or  four  days. 

Counter-irritation . — Counter-irritation  of  the  skin  is  of  but  little 


LOBAR    PNEUMONIA  275 

service  in  lobar  pneumonia.  Early  in  the  attack,  when  there  is  pain, 
a  mustard  plaster, — one-third  mustard  and  two-thirds  flour, — mixed 
to  a  paste,  spread  on  cheese-cloth,  and  placed  over  the  involved  area 
will  give  signal  relief.  It  may  be  repeated  at  intervals  of  from  four 
to  five  hours.  This  form  of  counter-irritation  is  also  useful  in 
convalescence  in  delicate  children  when  the  lung  clears  slowly. 
The  examination  of  these  cases  usually  reveals  feeble  breathing 
and  many  mucous  rales.  In  such  cases  two  or  three  applications 
daily  until  the  lung  clears  will  answer.  The  application  should  be 
kept  on  until  the  skin  is  well  reddened.  If  this  does  not  take  place 
in  ten  minutes,  the  mixture  of  mustard  and  flour  should  be  made 
stronger — one-half  mustard  to  one-half  flour.  In  a  few  cases  with 
delayed  resolution,  two  dry  cups  daily,  applied  directly  over  the  in- 
volved areas,  have  been  of  much  service. 

The  Diet. — See  Diet  in  Illness,  page  133. 

Antipyretics. — Whetherornot  antipyretic  measures  are  to  be  used, 
and  the  nature  of  the  antipyretic  to  be  advised,  depends  upon  the  case 
and  the  family  possibilities  as  to  care  and  nursing.  One  child  will  bear 
a  temperature  without  inconvenience  which  would  seriously  compro- 
mise the  chances  of  recovery  of  another,  so  that  the  thermometer  is 
not  the  only  guide.  The  eflfect  of  the  fever  upon  the  patient  must 
guide  us.  Some  children  will  be  delirious  and  restless  at  103°  F. 
and  will  need  antipyretic  treatment.  A  temperature  of  104°  F. 
rarely  needs  interference.  A  rise  of  one  degree  F.  will  usually  mean 
an  increase  of  twenty  to  thirty  heart-beats  per  minute.  In  lobar 
pneumonia,  I  prefer  that  the  temperature  should  not  go  above 
105°  F.,  even  if  at  the  time  the  child  shows  but  httle  inconvenience. 
Such  a  temperature  means  an  unnecessary  increase  in  the  amount 
of  work  required  of  the  heart,  which  instead  demands  relief  in  such 
an  emergency. 

Cold  water,  when  it  can  be  intelligently  applied,  is  the  best 
means  of  reducing  fever.  It  may  be  used  either  in  the  form  of  a 
sponge-bath  or  a  cool  pack.  The  sponge-bath  (page  30)  answers 
in  a  few  cases  in  which  the  temperature  is  readily  influenced.  It 
may  be  repeated  at  intervals  of  from  two  to  four  hours.  As  a  rule, 
the  cool  pack  (page  481)  will  be  required,  especially  if  the  fever 
is  particularly  high.  The  sponge-bath,  while  not  controlHng  the 
fever  as  well  as  does  the  pack,  possesses  the  advantage  that  the 
most  ignorant  can  safely  use  it.  It  really  amounts  to  nothing  more 
than  sponging  the  entire  body  with  cool  water  or  alcohol  and  water. 
The  cool  pack  requires  a  trained  nurse  or  a  very  intelligent  mother, 
either  of  whom  should  be  instructed  by  the  physician  as  to  its  use. 
When  properly  applied,  and  when  the  packs  or  baths  agree,  prompt 
improvement  in  the  immediate  symptoms  follows  their  use;  the 
child,  previously  restless,  and  perhaps  delirious,  falls  into  a  quiet 
sleep.    The  temperature  falls  two  or  three  degrees,  the  pulse  becomes 


276  DISEASES   OF    THE    RESPIRATORY   TRACT 

slower  and  fuller,  the  respiration  less  frequent,  and  when  properly 
given,  I  have  never  seen  a  pack  or  bath  do  harm  to  a  child.  In 
fact,  they  are  most  grateful  to  the  patients,  who,  when  old  enough, 
have  asked  to  have  the  towel  made  cooler  when  it  became  warm 
and  dry  from  the  heat  of  the  body. 

Heart  Stimulants . — A  child  must  never  be  given  a  heart  stimulant 
simply  because  he  has  pneumonia.  Heart  stimulation  is  usually  em- 
ployed too  early  in  the  attack.  When  the  pulse  shows  signs  of 
weakness,  whether  by  its  rapidity,  its  irregularity,  or  its  reduced 
volume,  then  it  is  time  for  stimulants.  For  a  very  rapid  pulse,  i.  e., 
over  one  hundred  and  fifty,  tincture  of  strophanthus  has  answered  bet- 
ter in  my  hands  than  any  other  means  of  stimulation.  For  a  child 
from  six  months  to  one  year  old,  I  order  one  drop  every  two  hours — at 
least  six  doses  in  twenty-four  hours;  for  a  child  from  one  to  three 
years  old,  one  or  two  drops  at  intervals  of  two  hours — at  least  six 
doses  in  twenty-four  hours;  for  a  child  of  three  years  or  over,  two 
or  three  drops  at  intervals  of  two  hours — at  least  six  doses  in  twenty- 
four  hours.  If  the  case  is  a  very  serious  one,  the  strophanthus 
may  be  given  every  two  hours  during  the  entire  twenty-four;  but, 
if  the  conditions  permit,  it  is  better  to  disturb  the  patient  as  in- 
frequently as  possible  during  the  night. 

When  the  pulse  is  irregular  and  intermittent,  with  reduced 
volume,  then  strychnin  is  the  remedy.  For  a  child  from  six  months 
to  a  year  old,  -g^^-  grain  is  to  be  given  every  three  hours — six  doses 
in  twenty-four  hours;  from  the  first  to  the  second  year,  ^^-^  grain 
at  three-hour  intervals — six  doses  in  twenty-four  hours;  after  the 
second  year,  yio"  grain  may  be  given  at  intervals  of  three  or  four 
hours — six  doses  in  twenty-four  hours.  Children  who  are  under 
strychnin  medication  should  be  carefully  watched  for  signs  of  the 
physiologic  effects  of  the  drug ;  the  first  symptoms  being  an  unusual 
susceptibility  to  sudden  noise  and  a  slight  fibrillary  twitching  of 
the  muscles  of  the  face  and  the  backs  of  the  hands.  Instructions 
should  be  given,  when  these  symptoms  appear,  to  discontinue 
the  drug  until  the  next  visit  of  the  physician.  I  have  repeatedly 
noticed  these  signs  of  the  physiologic  effects  of  the  administration 
of  strychnin,  and  they  need  cause  no  anxiety;  in  fact,  they  are 
necessary  in  order  to  get  the  full  benefit  of  the  drug.  However, 
it  is  only  in  the  most  severe  cases  that  the  drug  should  be  pushed 
to  such  an  extent. 

When  the  circulation  of  the  skin  is  deficient,  with  cold  extremi- 
ties and  cyanosis,  indicated  by  blueness  of  the  finger-nails  and 
lips,  nitroglycerin  is  indicated.  For  a  child  under  one  year  of  age, 
•3^  grain  may  be  given  at  intervals  of  two  or  three  hours — six 
doses  in  twenty-four  hours ;  for  a  child  from  one  to  three  years  of  age, 
g-g-g-  grain  at  three-hour  intervals — six  doses  in  twenty-four  hours; 
after  the  third  year 


LOBAR    PNEUMONIA  277 

doses  in  twenty-four  hours.  Nitroglycerin,  if  given  in  large  doses, 
produces  headache,  of  which  older  children  will  complain,  and 
nurslings  will  show  their  discomfort  by  restlessness  and  crying. 

Digitahs  is  rarely  used  as  a  heart  stimulant  in  young  children. 
It  disturbs  the  stomach  and  the  remedies  mentioned  above  meet 
the  conditions  much  better.  The  ammonium  preparations  are 
not  employed  because  their  administration  even  for  a  short  period 
invariably  interferes  with  nutrition  by  diminishing  the  digestive 
capacity. 

Camphor  and  musk,  recommended  by  some,  have  a  very  tran- 
sient stimulating  effect,  and  in  my  hands  have  been  ineffective. 

Alcohol  is  often  prescribed  too  early  in  pneumonia  in  children. 
Many  of  my  cases  of  pneumonia  pass  through  an  entire  attack 
without  one  drop  of  alcohol.  Alcohol  in  any  form  should  be  avoided 
early  in  the  disease.  Later,  when  the  case  is  doing  badly,  when  the 
strychnin  and  strophanthus,  alone  or  in  combination,  fail,  then 
alcohol  may  be  given,  and  then  it  may  be  a  Hfe-saving  measure. 
It  is  indicated  at  this  time  because  it  sustains  the  patient  when 
regular  food  assimilation  is  impossible,  and  at  the  same  time  it 
stimulates  the  heart.  Under  one  year  of  age  I  give  from  eight 
to  thirty  drops  of  brandy,  at  two-hour  intervals;  from  one  to  two 
years  of  age,  fifteen  drops  to  one  dram  at  two-hour  intervals;  over 
two  years,  one  to  two  drams  at  two-hour  intervals.  Cases  which 
show  profound  sepsis  will  require  and  consume  an  enormous  quan- 
tity of  alcohol  without  showing  the  slightest  intoxicating  effect. 
When  resident  physician  of  the  New  York  Infant  Asylum,  a  child 
fourteen  months  of  age  ill  with  diphtheria  was  given  four  ounces 
of  brandy  in  twenty-four  hours  without  showing  signs  of  stupor 
or  intoxication. 

Hypodermic  Stimulation. — -The  use  of  hypodermic  stimulation  in 
children  is  to  be  advised  onlv  in  an  emergencv,  or  when  the  stomach 
becomes  intolerant.  If  the  dietetic  means  suggested  are  carried  out, 
and  if  disturbing  drugs  such  as  the  ammonium  salts,  heavy  syrups, 
etc.,  are  omitted,  there  will  rarely  be  any  occasion  to  resort  to  hvpo- 
dermic  stimulation.  But  when  indicated  the  doses  suggested  for 
the  stomach  may  be  given  hypodermically,  with  the  exception  of 
alcohol,  which  should  not  thus  be  given  in  quantities  greater  than 
one-half  dram  of  brandy  or  whisky  at  one  time. 

Cases  will  be  encountered  in  which,  on  account  of  the  profound 
toxemia,  no  food  or  medicine  will  be  taken.  Here  the  giving  of 
stimulants  and  predigested  food  by  means  of  gavage  (page  135) 
will  be  of  material  assistance.  The  milk  used  should  be  completely 
peptonized,  and  to  it  whisky,  brandy,  and  stimulating  drugs  may 
be  added.  The  forced  feeding  should  not  be  used  oftener  than  once 
in  four  hours,  usually  once  in  six  hours  is  preferable.  When  thus 
given  the  amount  of  the  stimulants  should  be  increased. 


278  DISEASES    OF    THE    RESPIRATORY   TRACT 

Colon  flushing  (page  496)  with  a  normal  salt  solution,  at  110° 
F.,  is  of  great  service  in  pneumonia  when  there  is  extreme  pros- 
tration. A  pint  or  more  of  the  solution  may  be  used  alone  or  com- 
bined with  one-half  dram  of  brandy  or  whisky.  The  fluid  should  be 
carried  high  up  into  the  descending  colon.  As  the  rectum  soon 
becomes  intolerant,  the  flushing  should  not  be  repeated  oftener  than 
once  in  six  or  eight  hours. 

Specific  Medication. — There  is  no  drug  known  which  will  cut 
short  or  abort  an  attack  of  lobar  pneumonia.  Mercury  in  the 
form  of  large  doses  of  calomel,  quinin,  salicylate  of  soda,  and  other 
drugs  have  no  specific  action.  As  previously  stated,  our  efforts 
must  be  directed  tow^ard  a  conservation  of  the  strength  of  the  patient 
by  placing  him  in  the  best  position  to  cope  with  the  disease.  This, 
with  careful  medication  to  meet  special  requirements  as  they  arise, 
constitutes  our  treatment  of  lobar  pneumonia,  and  has  given  us 
a  death-rate  of  only  2  percent  in  children  under  two  years  of  age. 
During  convalescence  great  care  is  needed  as  to  permitting  the  child 
to  resume  his  usual  habits  of  life,  for  in  these  matters,  as  well  as 
in  regard  to  food  and  exercise,  we  must  make  haste  slowly. 

PRIMARY  PLEURISY 

Acute  primary  non-rheumatic  pleurisy  is  a  very  rare  condition 
in  children.  I  have  seen  but  four  cases  under  nine  years  of  age — one 
was  eight,  one  seven,  and  one  four  years  of  age,  and  one  only  fif- 
teen months  old. 

Its  onset  is  practically  the  same  as  in  adults.  There  is  localized 
pain,  the  so-called  "stitch  in  the  side,"  the  respiration  is  rapid, 
fortv  to  sixty  to  the  minute,  and  shallow;  the  skin  is  dry  and  hot; 
the  cough  is  teasing,  and,  on  account  of  the  pain  which  it  causes, 
is  partially  suppressed  by  the  patient.  Fever  is  present  which  is 
usually  quite  high,  102°  to  105°  F.  The  pulse  is  rapid,  one  hun- 
dred and  twenty  to  one  hundred  and  fifty  to  the  minute.  In  only 
one  of  my  cases  was  the  pleuritic  inflammation  followed  by  effu- 
sion. This  was  in  the  child  fifteen  months  old.  The  fluid  in  this 
case  was  sterile.  So  far  as  we  could  learn  there  was  no  rheumatic 
association  in  any  of  the  cases. 

Treatment. — The  treatment  which  proved  successful  in  the  four 
cases  was  rest  in  bed.  The  patients  were  given  a  reduced  diet  of  milk, 
broths,  and  gruel.  The  fever  was  not  of  a  very  persistent  character 
and  was  readily  controlled  by  sponge-baths  (page  30).  For  the  relief 
of  the  pain,  a  flaxseed  and  mustard  poultice, — one  part  of  mus- 
tard to  nine  parts  of  flaxseed, — applied  as  hot  as  could  be  borne 
by  the  back  of  the  nurse's  hand,  and  changed  every  half  hour,  gave 
much  relief  during  the  acute  stage.  After  the  first  twenty-four 
hours,  however,  poultices  are  of  little  value.  Strapping  the  affected 
side  with  strips  of  Z.  O.  plaster  will  give  much  comfort  where  the 


SECONDARY   PLEURISY  279 

pain  continues  after  the  second  day.  Tincture  of  aconite  in  doses 
of  one  drop  every  hour  was  given  to  the  older  children  until  ten 
drops  had  been  given.  It  produced  a  fairly  free  diaphoresis  and 
made  the  patients  more  comfortable.  A  grain  of  calomel  in  divided 
doses  was  given  early  in  the  attack,  one -tenth  of  a  grain  being 
given  every  hour.  The  duration  of  the  acute  symptoms  was  ordinar- 
ily from  twelve  to  twenty-four  hours;  the  entire  duration  of  the 
illness  ranging  from  five  days  to  one  week.  In  the  youngest  child, 
with  effusion,  absorption  appeared  to  be  stimulated  by  the  intro- 
duction of  the  needle  and  the  withdrawal  of  a  small  amount  of 
fluid,  the  remainder  quickly  disappearing  afterward.  To  relieve 
the  cough,  small  doses  of  codein,  one-tenth  of  a  grain  every  two 
hours,  were  given  the  older  children. 

SECONDARY  PLEURISY 

Pleuritic  inflammation,  as  a  complication  of  disease  of  the  lungs 
or  as  a  result  of  disease  in  other  parts  of  the  body,  is  of  very  fre- 
quent occurrence  in  the  young.  Pneumonia  furnishes  by  far  the 
greatest  number  of  cases,  lobar  more  than  catarrhal  or  broncho- 
pneumonia. Tuberculosis  is  possibly  the  next  most  frequent  cause 
of  secondary  pleurisy,  which  is  almost  always  without  effusion  of 
any  moment.  If  the  disease  is  of  considerable  duration,  adhesions 
binding  the  lung  to  the  chest  wall  will  invariably  be  found  at  au- 
topsy. Secondary  pleurisy  may  follow  pericarditis.  Such  an  occur- 
rence, however,  is  extremely  rare.  It  has  never  happened  in  one  of 
my  cases. 

Secondary  pleurisy  may  be  either  what  is  known  as  a  dry  pleu- 
risy or  a  pleurisy  with  effusion.  When  dry  pleurisy  exists,  the 
pleura  has  lost  its  normal  luster  and  is  covered  early  in  the  attack 
with  a  shght  fibrinous  exudation.  As  the  disease  progresses,  the 
exudation  may  be  more  extensive,  resulting  in  thick  fibrous  bands 
and  masses,  a  network  oftentimes  being  formed  in  which  is  en- 
closed a  thick  gelatinous  material  composed  largely  of  pus  cells. 
Repeatedly  at  autopsy  I  have  found  the  lung  so  thoroughly  bound 
to  the  chest  wall  that  its  removal  without  the  aid  of  force  was 
impossible. 

In  pleurisy  with  effusion,  a  fluid  composed  either  of  pus  or  serum 
will  be  found  in  the  pleural  cavity.  I  have  never  seen  a  case  in  which 
the  effusion  in  a  pleurisy  secondary  to  pneumonia  did  not  contain 
bacteria.  The  fluid  upon  withdrawal  may  appear  clear,  yet  bac- 
teriologic  examination  will  show  that  it  is  not  sterile.  It  may  be, 
and  often  is,  the  first  manifestation  of  a  purulent  pleurisy  or  empy- 
ema. In  the  very  young,  rheumatic  pleurisy  (page  463)  is  extremely 
rare.     I  have  seen  but  six  cases  in  children  under  four  years  of  age. 

Treatment. — The  treatment  of  dry  secondary  pleurisy  is  usually 
that  of  the  disease  which  it  complicates.     I  have  never  known  any 


28o  DISEASES    OF   THE   RESPIRATORY   TRACT 

special  medication  to  be  of  any  practical  value.  Tonics  and  suppor- 
tive measures  generally  are  of  service.  Anything  that  will  improve 
the  condition  of  the  patient  should  be  brought  into  use.  A  change 
of  residence  from  the  city  to  the  country  for  those  who  can  afford 
it,  or  an  outdoor  life  in  the  city  for  those  who  cannot  avail  them- 
selves of  such  a  change  is  always  beneficial.  Counter-irritation 
to  the  chest  with  mustard  or  iodin  will  often  give  relief  to  the 
patient  if  there  is  pain,  but  otherwise  it  possesses  no  value.  Occa- 
sionally there  is  a  sense  of  "tightness  "  and  constriction  of  the 
chest,  which  amounts  to  pain,  and  this  condition  mustard  or  iodin 
will  relieve.  Painting  the  affected  area  with  tincture  of  iodin 
every  second  or  third  night  has  in  a  few  cases  afforded  some  relief. 
The  administration  of  iodids  as  an  aid  to  absorption  is  of  question- 
able value  and  is  very  apt  to  disturb  digestion.  The  application 
of  a  mustard  plaster  (page  493),  one-third  mustard  and  two-thirds 
flour,  to  the  bare  skin  over  the  diseased  area  for  ten  or  fifteen  min- 
utes, at  intervals  of  six  or  eight  hours,  w^ll  add  to  the  comfort  of 
the  patient.  When  after  recovery  from  the  pneumonia  or  the 
empyema  adhesions  persist,  with  restricted  lung  action,  active 
exercise  in  the  open  air  is  to  be  encouraged.  For  younger  patients 
horseback-riding,  the  bicycle,  and  breathing  exercises,  with  active 
games  in  which  they  become  interested  and  which  require  deep 
breathing,  do  better  than  anything  else.  The  glass  tubes  of  James, 
recommended  by  many,  wnth  which  the  child  blows  colored  water 
from  one  bulb  to  another,  have  been  of  no  value  in  my  hands,  because 
their  use  will  not  be  persisted  in  long  enough  for  benefit.  The 
apparatus  is  a  toy.  The  child  soon  tires  of  it,  as  of  any  toy,  and 
its  use  will  be  discontinued. 

PRIMARY  TUBERCULOUS  PLEURISY 
Primary  pleurisy  due  to  tuberculous  infection  is  exceedingly 
rare  in  children.  I  have  seen  but  one  such  case,  and  that  in  a  child 
two  years  of  age.  Three  ounces  of  fluid  were  removed  from  the 
chest;  in  four  weeks  signs  of  infiltration  appeared  in  the  lung; 
and  in  eight  weeks  after  the  attack  of  pleurisy  the  child  died  from 
general  tuberculosis.  The  treatment  is  the  same  as  for  pulmonary 
tuberculosis. 

EMPYEMA 
By  empyema  we  understand  a  collection  of  pus  in  the  pleural 
cavity,  the  pus  being  the  product  of  an  inflammation  of  the  pleura 
which  has  become  infected  with  pathogenic  organisms.  Bacterio- 
logic  examination  of  the  pus  shows  the  pneumococcus  to  be  present 
in  pure  culture  in  a  large  percentage  of  the  cases.  The  strepto- 
coccus and  staphvlococcus,  alone  or  in  combination  with  the  pneu- 
mococcus, are  seen  less  frequently.     The  tubercle  bacillus  is  rarely 


EMPYEMA  281 

a  factor  in  empyema  of  the  young.  In  forty-five  cases  I  have  seen 
but  one  in  which  it  was  present.  Empyema  is  rarely  a  primary 
disease.  It  is  usually  secondary  to  pneumonia,  only  very  rarely 
to  a  suppurative  process  in  another  part  of  the  body.  In  all  my 
own  cases  it  followed  pneumonia,  and  if  an  accurate  history  were 
obtainable  this  would  be  the  record  of  fully  95  percent  of  the  cases. 

The  development  of  the  average  case  of  empyema  would  be  very 
much  as  follows:  The  child  had  catarrhal  pneumonia  or  broncho- 
pneumonia, running  the  usual  course  as  to  fever,  respiration,  pulse, 
and  prostration,  and  after  a  time,  from  six  to  twelve  days,  an  im- 
provement in  the  symptoms  was  noticed,  the  pulse  and  respiration 
became  slower,  and  the  child  brighter.  For  twenty-four  hours 
the  temperature  range  was  lower.  During  the  height  of  the  pneu- 
monia it  was  perhaps  104°  or  105°  F.,  now  it  ranges  from  100°  to 
102°  F.,  occasionally  dropping  to  99°  F.  Such  a  temperature  con- 
tinues for  a  few  days,  when  it  is  noticed  that  it  is  lower  in  the  morn- 
ing than  in  the  evening,  although  the  evening  temperature  may 
not  be  over  102°  F.,  perhaps  occasionally  reaching  103°  F.  The 
child  coughs,  the  pulse  is  rapid,  120  to  140,  the  respirations  accel- 
erated, 40  or  over.  The  appetite  is  poor.  These  symptoms,  with 
progressive  emaciation,  may  continue  for  weeks  if  the  condition  is 
not  recognized. 

The  course  of  development  of  an  empyema  after  a  lobar  pneu- 
monia is  somewhat  different.  The  crisis  occurs  and  the  tempera- 
ture falls  to  normal;  all  goes  well  for  a  few  days, — four  or  five, 
perhaps, — when  a  slight  evening  rise  occurs.  The  temperature 
is  lower  the  next  morning,  but  not  quite  normal.  The  followdng 
evening  it  is  higher  than  the  preceding.  Such  a  temperature  range 
is  almost  pathognomonic  of  empyema. 

Empyema  is  often  mistaken  for  tuberculosis,  malaria,  typhoid 
fever,  or  unresolved  pneumonia.  An  enumeration  of  the  points 
necessary  for  making  a  differential  diagnosis  is  not  within  the  scope 
of  this  work.  It  may  be  said,  however,  that  when  the  physician 
is  in  doubt,  the  aspirating  needle  should  always  be  used  (Fig.  27). 
If  the  needle  is  sterile — and  there  is  no  excuse  for  its  being  other- 
wise— and  if  the  skin  is  properly  prepared,  there  is  no  danger  of 
infection.  The  skin  should  be  prepared  as  follows:  A  thorough 
scrubbing  with  tincture  of  green  soap  should  be  followed  by  scrub- 
bing with  a  solution  of  bichlorid  of  mercury,  i  :  2000;  this,  in  turn, 
is  followed  by  washing  with  alcohol,  which  is  then  applied  on  absor- 
bent cotton  and  allowed  to  remain  for  at  least  one  minute  at  the  site 
of  the  proposed  puncture.  It  is  well  to  use  a  large  needle,  so  that 
in  case  the  pus  is  thick  it  will  the  more  easily  pass  through  it.  The 
child  should  be  held  in  an  upright  position,  the  needle  introduced 
at  the  site  of  the  greatest  dullness.  After  the  withdrawal  of  the 
needle,  adhesive  plaster  should  be  placed  over  the  wound. 


282 


DISEASES   OF   THE    RESPIRATORY   TRACT 


Treatment. — The  pus  being  located,  operation  is  the  only  means 
of  treatment.  Aspiration  of  the  pus  should  not  be  considered  a  sub- 
stitute for  incision.  In  a  recent  case  in  a  young  child  under  two  years 
of  age  an  incision  with  local  anesthesia  is  all  that  will  be  required. 
In  older  children,  or  in  a  prolonged  case  in  a  young  child,  a  resec- 
tion of  the  rib  is  to  be  advised  as  furnishing  a  much  freer  drainage. 
■Occasionally  cases  are  seen  among  older  children  in  which,  on  account 
of  a  very  severe,  persisting  pneumonia,  it  will  not  be  safe  to  use 
a  general  anesthetic.  In  such  cases  an  incision  may  be  made  under 
cocain — a  4  percent  solution  being  injected  into  the  skin  at  the  site 
of  the  proposed  incision.     Such  an  operation  will  relieve  the  imme- 


FiG.  27. — Potain's  Modification  of  Dieulafoy's  Aspirator. 


diate  symptoms — the  displacement  of  the  heart  and  the  diflficult 
breathing.  The  resection  of  a  rib  may  safely  be  undertaken  after 
a  week  or  two,  when  considerable  improvement  will  have  taken  place 
in  the  general  condition.  As  soon  as  the  cavity  is  opened,  two 
half-inch  drainage-tubes  from  two  to  four  inches  in  length  joined 
with  a  large  safety-pin  are  inserted.  Gauze  is  packed  around  the 
tubes  and  against  the  skin,  and  upon  this  the  pin  rests.  Sterile 
gauze  is  placed  over  the  end  of  the  tubes  as  soon  as  possible  after  their 
introduction,  in  order  to  prevent  a  too  free  escape  of  pus.  When 
the  pus  is  allowed  gradually  to  escape,  much  less  shock  will  be 
experienced.  Over  the  gauze  two  or  three  layers  of  absorbent 
cotton  are  placed,  and  over  this  the  bandage.     The  dressing  should 


KMPYEMA  283 

be  changed  every  day  and  the  tubes  shortened  as  the  lung  expands. 
This  expansion  will  be  indicated  by  the  resulting  outward  displace- 
ment of  the  tubes.  After  the  evacuation  of  the  pus,  the  pulse  usu- 
ally falls  to  normal  or  nearly  normal,  where  it  remains.  Occa- 
sionally, however,  cases  are  seen  in  which  this  expected  result 
does  not  follow  the  operation. 

Illustrative  Cases. — In  one  of  my  cases  the  operation  was  followed 
by  a  free  discharge  of  pus,  but  with  no  relief  whatever  to  the  symp- 
toms. An  examination  of  the  chest  revealed  at  the  apex  of  the  lung 
a  pocket  of  pus  which  had  become  walled  off  by  adhesions.  The 
case  was  one  of  three  months'  duration  when  it  came  under  my 
care.  A  second  operation  removed  about  six  ounces  of  pus,  but 
the  child  died  from  exhaustion  about  twenty-four  hours  after- 
ward. Autopsy  showed  that  the  pleural  cavity  was  divided  into 
two  distinct  pus  sacs  by  a  firm  band  of  adhesions. 

In  another  case,  that  of  a  girl  of  five  years,  on  account  of  the  re- 
duced condition  of  the  child, — the  empyema  following  a  pneumonia, 
— an  incision  was  made  instead  of  a  resection  of  the  rib.  The  temper- 
ature fell  to  normal  and  all  the  symptoms  improved  for  a  few  days, 
when  an  evening  rise  to  101°  F.  and  over  was  noted  which  in  two  or 
three  days  reached  103°  F.  There  was  a  discharge  which  saturated 
the  dressings,  although  they  were  changed  every  three  or  four  hours. 
Our  inability  to  locate  an  independent  pus  pocket,  the  continued 
fever,  and  a  strong  odor  to  the  discharge,  suggested  the  proba- 
bility of  insufhcient  drainage.  In  spite  of  the  fever,  the  child  having 
gained  considerably  in  strength,  a  second  operation  was  decided 
upon  to  enlarge  the  wound.  She  was  anesthetized  and  two  inches 
of  rib  removed,  when  quantities  of  necrotic  fibrinous  material  were 
found  in  the  pleural  cavity.  These  were  removed  with  the  finger 
and  dressing  forceps,  when  the  temperature  immediately  fell  to 
normal  and  the  child  made  a  perfect  recovery.  Irrigation  of  the 
cavity  had  been  of  no  avail. 

Ordinarily  the  tubes  should  not  be  removed  until  from  four  to 
six  weeks  after  the  operation.  They  should  remain  in  position  until 
a  free  respiratory  murmur  is  heard  all  over  the  affected  side  up  to 
the  site  of  operation  in  the  chest  wall.  When  the  lung  is  fully 
expanded,  the  tubes  will  be  forced  out  and  found  in  the  dressings. 
Irrigation  of  the  pleural  cavity  is  not  to  be  advised  as  a  routine 
measure,  and  with  sufKicient  drainage  it  will  not  be  necessary.  The 
cases  which  require  irrigation  on  account  of  continued  fever  and 
insufficient  discharge  require  a  resection  of  the  rib.  Should  a 
second  operation  be  refused,  or  be  inadvisable,  on  account  of  the 
tender  age  or  the  general  weakness  of  the  patient  or  on  account  of 
some  compHcation,  such  as  a  pericarditis,  a  daily  irrigation  with 
a  sterile  normal  salt  solution  may  be  undertaken. 


284  DISEASES   OF   THE   RESPIRATORY  TRACT 


DOUBLE  EMPYEMA 

Two  of  the  forty-five  cases  of  empyema  which  I  have  seen  were 
bilateral,  both  pleural  sacs  being  involved.  In  such  cases  both  sides 
should  not  be  opened  at  the  same  time,  on  account  of  the  danger 
of  collapse  of  the  lungs.  There  are  usually  adhesions  present  suf- 
ficiently strong  to  prevent  this,  but  we  have  no  means  of  knowing 
this  beforehand.  In  both  of  my  cases,  the  left  pleural  cavity  was 
opened  first,  in  order  to  relieve  the-  pressure  upon  the  heart  and 
the  great  vessels.  In  one  case  a  considerable  quantity  of  pus  was 
removed  from  the  right  side  by  aspiration,  at  the  time  of  the  opera- 
tion on  the  left  side.  The  right  side  was  operated  upon  four  days 
later,  by  which  time  sufficient  adhesions  had  formed  to  preveni 
collapse  of  the  lungs.  The  patient,  a  boy  of  two  years,  made  an 
excellent  recovery. 

The  second  case  was  one  year  of  age.  Pus  had  been  present 
in  both  sides  for  a  considerable  time.  The  left  side  was  opened 
first.  The  sac  on  the  right  side  was  smaller  than  that  on  the  left, 
and  was  operated  on  by  incision  three  days  later.  The  child  was 
very  much  reduced  by  the  protracted  illness.  In  spite  of  the 
free  daily  irrigation  of  both  cavities  the  typical  temperature  per- 
sisted until  death,  probably  on  account  of  the  very  extensive  sup- 
purating surfaces.  The  child  died  from  exhaustion  twelve  days 
after  the  second  operation. 

EMPYEMA  NECESSITATIS 
Spontaneous  rupture  of  the  pleural  sac  may  occur  in  cases  of 
empyema  of  considerable  duration  which  are  not  properly  diagnosed, 
or  not  operated  upon,  if  diagnosed.  Cases  of  this  nature  have 
been  reported  in  which  the  pus  ruptured  into  the  esophagus,  into 
the  bronchi,  or  through  the  diaphragm  into  the  peritoneal  cavity. 
In  two  of  the  cases  seen  by  me  spontaneous  rupture  occurred.  In 
the  first,  pus  ruptured  into  the  bronchi.  The  patient  was  a  well- 
nourished  boy  three  years  of  age.  The  pus  was  sacculated  over 
the  anterior  portion  of  the  left  lung.  The  parents,  not  particularly 
intelligent  people,  objected  to  the  operation,  and  while  it  was  under 
consideration  by  them,  two  or  three  days  after  the  diagnosis  was 
made,  the  pus  ruptured  into  the  bronchi  and  was  discharged  from 
the  mouth  in  large  quantities  during  a  coughing  paroxysm.  The 
child  made  an  uninterrupted  recovery.  The  other  case,  a  boy 
of  two  years,  came  under  observation  for  a  soft,  fluctuating  swelling 
the  size  of  a  small  orange,  on  the  right  side  immediately  below 
the  nipple.  Exploration  with  a  hypodermic  needle  showed  pus. 
An  incision  was  made  and  about  three  ounces  of  pus  discharged. 
When  the  sac  was  emptied  it  was  found  to  communicate  with  the 
right  pleural  cavity  by  an  opening  between  the  seventh  and  eighth 


PULMONARY   TUBERCULOSIS  285 

rib.     The    wound    was    dressed    and    the    child    recovered    without 
further  comphcations. 

PULMONARY  TUBERCULOSIS 

Pulmonary  tuberculosis  in  young  children  under  the  fifth  year 
of  age  rarely  occurs  independent  of  tuberculosis  elsewhere.  At 
this  early  period  of  life  the  disease  is  usually  acute  and  fatal.  After 
the  fifth  year,  particularly  after  the  seventh  or  eighth  year,  the 
disease  assumes  the  characteristics  which  mark  its  presence  in  the 
adult.     Even  at  this  age  it  is  by  no  means  of  frequent  occurrence. 

As  with  the  adult,  so  with  the  child,  the  earlier  the  disease  is  recog- 
nized and  the  earlier  the  treatment  is  begun,  the  better  will  be  the 
result.  The  discovery  of  tubercle  bacilli  in  the  sputum  should 
not  be  required,  before  beginning  rigid  therapeutic  measures.  Loss 
in  weight,  cough,  and  the  characteristic,  localized,  auscultation 
signs,  however  slight,  are  sufficient  to  warrant  active  treatment. 
Given,  for  example,  an  apex  involvement  in  a  child  from  eight 
to  ten  years  of  age,  with  the  advantages  which  will  be  mentioned, 
and  the  prognosis  is  better  than  in  adults  with  equal  pulmonarv 
involvement,  who  have  equal  advantages. 

Treatment. — Climate. — For  those  who  are  so  situated  financially 
as  to  have  the  advantages  of  an  equable  climate,  a  change  of  resi- 
dence or  sanitarium  treatment  should  be  provided.  A  dry  climate 
of  equable  temperature  that  will  allow  the  tuberculous  child  to 
spend  the  greatest  number  of  hours  in  the  open  air  is  the  best 
climate  for  the  patient.  The  climate  of  southern  New  Mexico  and 
Arizona  is  best  for  these  cases.  I  have  had  children  do  well  in  the 
Adirondacks  and  in  Sullivan  County,  New  York,  but  the  severity 
of  the  winter  makes  these  localities  less  desirable. 

Diet. — Equally,  if  not  more  important  than  climate,  is  the  nutri- 
tion of  the  patient.  This  must  be  raised  to  the  highest  possible  stan- 
dard, but  there  should  be  no  overfeeding — a  procedure  of  no  value  in 
any  disease  in  the  young.  My  patients  have  improved  most  on  a 
high-proteid  diet  of  milk,  meat,  and  eggs,  and  a  high-proteid  cereal, 
such  as  oatmeal,  and  the  legumes, — dried  peas,  beans,  and  lentils, — 
which  are  given  in  the  form  of  a  puree.  I  have  found  it  advisable 
not  to  insist  that  a  definite  amount  of  food  shall  be  given  in  twenty- 
four  hours,  but  the  mother  or  nurse  is  told  that  these  foods,  prepared 
in  different  ways  so  that  the  child  will  not  tire  of  them,  are  to  form 
a  considerable  part  of  the  diet.  Green  vegetables,  fruits,  and  plain 
desserts  are  given  to  furnish  variety  and  to  stimulate  the  appetite. 
When  three  meals  a  day  are  given,  with,  perhaps,  a  glass  of  milk  in 
the  middle  of  the  afternoon,  I  have  been  able  to  maintain  better 
nutrition  than  with  more  frequent  feedings.  Forced  feeding  in 
children  often  defeats  its  own  purpose  by  producing  disgust  for 
or  intolerance  of  food.     The  child  should  be  fed  on  nutritious  food, 


286  DISEASES   OF   THE    RESPIRATORY   TRACT 

for  which  an  appetite  must  be  developed ;  for,  inasmuch  as  recovery- 
is  dependent  largely  upon  nutrition,  the  question  of  appetite  and 
food  capacity  is  of  paramount  importance.  Candy,  sweet  crackers, 
and  other  harmful  articles  should  not  be  allowed.  In  order  to 
satisfy  the  candy  craving,  a  small  quantity  of  sweet  chocolate  may 
be  given  after  the  noonday  meal.  The  best  appetizers  that  we 
can  furnish  the  child  are  reasonable  exercise,  entertainment  and 
play  that  does  not  fatigue,  and  fresh  air  in  abundance,  and  upon 
our  ability  to  supply  these  requirements  depends,  to  a  large  degree, 
the  outcome  of  the  case. 

Tenement  Cases. — The  majority  of  the  cases  of  pulmonary  tuber- 
culosis in  children  cannot  be  sent  to  sanitariums  or  to  health  resorts. 
They  must  be  treated  in  their  homes.  This  I  have  done  successfully 
in  New  York  city  even  among  the  tenement  population.  The  basic 
principles  of  management  are  a  properly  directed  hfe,  good  food,  and 
fresh  air.  These  are  the  weapons  for  fighting  the  enemy,  regard- 
less as  to  whether  the  residence  is  among  the  rich  or  poor,  in  town 
or  country.  It  is,  however,  among  the  tenement  population  that 
we  experience  the  greatest  difficulty.  It  is  not  enough  to  tell  these 
people  how  the  child  is  to  be  fed.  The  feeding  as  directed  entails 
considerable  expense,  and  the  parents  may  not  be  able  to  meet 
it.  After  personal  investigation,  which  should  be  made  in  every 
case  if  it  is  demonstrated  that  proper  nutrition  or  suitable  clothing 
are  impossible,  I  explain  the  situation  to  some  charitably  inclined 
person  of  means,  and  have  yet  to  know  of  an  instance  where  cloth- 
ing and  a  small  but  sufficient  weekly  food-allowance  were  not 
forthcoming.  To  the  best  of  my  knowledge  the  child  himself  has 
always  had  the  benefit  of  the  charity,  and  I  have  investigated  such 
cases  closely.  An  allowance  of  twenty-five  cents  a  day  for  fresh  meat 
and  milk  has  oftentimes  furnished  what  was  required  to  bring  the  case 
to  a  favorable  termination.  The  uselessness  of  much  of  our  medi- 
cal advice  to  the  poor  would,  on  slight  reflection  or  a  little  investi- 
gation, be  apparent.  The  physician  should  not  trust  to  chance 
for  results,  but  should  act  so  as  to  make  results.  In  addition  to 
the  diet  above  outlined,  the  advantages  of  an  outdoor  life,  and 
the  means  by  which  fresh  air  may  be  obtained  all  the  year  round, 
are  fully  explained.  Any  simple  direction  as  to  what  may  appear 
to  be  a  radical  procedure  is  rarely  carried  out  without  a  rational 
explanation  of  its  necessity.  During  the  daytime  the  child  is  kept 
outdoors.  In  the  park  or  in  the  streets  is  better  than  in  the 
house.  Close,  tightly  sealed,  sleeping  apartments  at  night,  however, 
will  undo  the  good  of  the  outdoor  life  during  the  day.  The  mother 
is  told  to  have  the  child  sleep  alone  in  the  largest  room  of  the  apart- 
ment, and  always  in  a  room  in  which  the  windows  are  opened. 
This  is  usually  possible.  A  sponge-bath  or  tub-bath  is  given  the 
child  at  bedtime,   followed  by  a  brisk  rubbing  with  a  towel.     If 


BRONCHIECTASIS  287 

there  is  much  emaciation,  an  oHve-oil  or  goose-oil  inunction  follows 
the  salt  bath.  Sometimes  these  directions  arc  followed  implicitly; 
at  other  times  they  are  forgotten.  It  is  astonishing,  however,  what 
rapid  improvement  will  follow,  when  a  tuberculous  child  of  the 
tenements  is  given  the  benefit  of  fresh  air,  day  and  night,  with 
suitable  food  and  cleanliness,  even  though  it  is  in  New  York  city. 

Tonics. — Among  the  more  fortunate  classes  the  same  treatment 
is  to  be  carried  out.  In  these,  however,  we  see  fewer  cases.  The 
usefulness  of  drugs  depends  to  a  large  degree  upon  an  increase  of 
food  capacity  which  their  use  may  cause.  Either  of  the  prescrip- 
tions written  below  may  be  alternated  with  cod-liver  oil  and  malt, 
each  being  given  for  five  days.  For  a  child  from  seven  to  tw^elve 
years  of  age,  the  following  are  useful  restoratives  and  appetizers: 

I^.     Ferri  et  quininge  citratis gr.  xxiv 

Vini  xerici oiv 

M.     Sig. — One  teaspoonful  in  water  three  times  a  day  after  meals. 

I^.     Tincturae  nucis  vomicae gtt.  Ixiv 

Extracti  ferri  pomati gr.  vj 

Ouininae  bisulphatis 5j 

M.  ft.  capsulae  No.  xxx. 

Sig. — One  after  each  meal. 

If  night-sweats  are  present,  from  o^^^  to  y^^o^  grain  of  atropin 
given  at  bedtime  will  often  furnish  relief.  The  dangers  of  infecting 
others  is  fully  explained  to  those  in  charge  of  the  patient.  Vari- 
ous devices  for  collecting  the  sputum  may  be  obtained  in  the  shops. 
A  cheap  and  effective  way  is  the  use  of  a  Japanese  paper  handker- 
chief, which,  when  used,  is  at  once  placed  in  a  paper  bag,  the  bag  and 
its  contents  being  burned  at  the  close  of  the  day. 

BRONCHIECTASIS 

Bronchiectasis  consists  of  a  dilatation  of  the  bronchi,  such  dila- 
tation being  usually  sacculated  or  cylindrical  in  form  and  always 
associated  with  an  interstitial  pneumonia.  In  a  child  eighteen 
months  of  age  who  died  from  bronchopneumonia  of  three  months' 
duration  with  terminal  sepsis,  there  were  several  small  cylindrical 
dilatations.  One  of  these  with  a  capacity  of  six  drams  was  found 
in  the  right  lung. 

Treatment. — The  treatment  of  the  condition  is  the  treatment  of 
interstitial  pneumonia,  and  little  can  be  accomplished  with  the  use  of 
drugs  except  such  as  will  improve  the  nutrition  of  the  patient.  Chil- 
dren with  this  unfortunate  pulmonary  disease  should  take  up  their 
permanent  residence  in  a  dry  climate  such  as  is  furnished  by  Colorado 
or  New  Mexico.  A  visit  of  a  few  months  or  a  year  is  of  but  little 
service.  I  have  used  the  iodids  and  the  bichlorid  of  mercury  for 
months  without  any  appreciable  improvement,  in  two  of  these  cases 
that  could  not  be  removed  from  town.     The  citrate  of  iron  and 


288  DISEASES   OF   THE    RESPIRATORY   TRACT 

quinin,  one  grain  in  a  dram  of  sherry  wine,  makes  a  good  appetizer 
for  these  cases.  It  may  be  given  in  one-fourth  glass  of  water  after 
meals.  Its  use  can  with  advantage  be  alternated  with  the  syrup 
of  the  hypophosphites  (Gardner),  one  to  three  drams  being  given 
daily  in  one-half  glass  of  water  after  meals.  Cod-liver  oil  may  be 
used  with  advantage  for  ten  days  out  of  a  month.  Its  continued 
use  sometimes  is  contraindicated,  as  it  is  apt  to  interfere  with 
digestion. 

In  one  of  the  cases  above  referred  to,  the  iron  was  given  for  ten 
days,  hypophosphites  for  ten  days,  and  the  oil  for  ten  days,  when 
the  procedure  was  repeated.  The  patient  continued  to  look  well, 
gained  in  weight,  and  remained  under  treatment  until  he  took 
up  an  occupation  and  passed  from  observation.  The  condition  of 
the  lung  had  remained  unchanged,  the  only  active  manifestation  of 
the  disease  being  the  expectoration  of  considerable  non-tuberculous 
pus  every  morning  on  rising. 

The  usual  outcome  of  those  cases  which  have  not  the  advantage 
of  climatic  influence  is  fatal.  Death  usually  results  from  tubercu- 
losis or  from  a  septic  process  in  some  other  portion  of  the  body. 


DISEASES  OF  THE  HEART 

PERICARDITIS 

Pericarditis  other  than  as  a  manifestation  of  rheumatism  is 
to  be  regarded  as  secondary  to  a  diseased  process  in  some  other 
portion  of  the  body. 

Treatment. — As  far  as  treatment  is  concerned,  cases  of  peri- 
carditis may  be  divided  into  two  groups,  those  of  rheumatic  origin 
and  those  due  to  the  invasion  of  the  known  pathogenic  organisms.  An 
immense  majority  of  the  cases  of  dry  pericarditis  and  of  pericarditis 
with  effusion  are  of  rheumatic  origin.  The  pericarditis  usually  is 
associated  with  endocarditis,  or  some  other  evidences  of  rheumatic 
infection  are  present.  As  a  manifestation  of  rheumatism,  peri- 
carditis may  precede,  be  associated  with,  or  follow  inflammation 
of  the  endocardium.  The  general  and  specific  drug  management 
of  pericarditis  is  largely  the  same  as  for  endocarditis  (page  291). 
The  ice-bag  is  used  as  in  endocarditis,  but  bhsters  are  not  applied. 
They  are  of  very  doubtful  utility  and  disturb  the  child  consider- 
ably, not  only  when  they  are  being  applied  but  for  days  after- 
ward. When  pericarditis  occurs  without  marked  endocardial 
involvement,  which  is  rare  in  the  young,  prolonged  rest  in  bed  is 
not  so  essential. 

Drugs. — For  the  excessive  rapidity  of  the  heart  action  which 
is  usually  present,  the  tinctures  of  strophanthus  and  aconite  are 
of  a  great  deal  of  service.  For  a  child  three  years  of  age,  one- 
half  drop  of  the  tincture  of  aconite  and  one  drop  of  the  tincture 
of  strophanthus  can  be  given  at  two-hour  intervals,  but  not  to  ex- 
ceed six  doses  should  be  given  in  twenty-four  hours.  After  the 
third  year,  one  drop  of  the  tincture  of  aconite  and  two  drops  of  the 
tincture  of  strophanthus  may  be  given  at  two-hour  intervals,  six 
doses  in  the  twenty-four  hours.  For  the  extreme  restlessness  which 
often  exists,  codein  or  paregoric  may  be  given.  For  a  child  under 
two  years  of  age,  paregoric  is  safer.  It  may  be  given  in  doses  of 
from  ten  to  twenty  drops  and  repeated  when  indicated  at  inter\^als 
of  two  or  three  hours.  Older  children,  between  the  second  and  sixth 
years,  should  be  given  codein  in  doses  of  from  one-tenth  to  one- 
sixth  grain.  After  the  sixth  year,  one-fourth  grain  may  be  given, 
to  be  repeated  at  three-hour  intervals  only,  and  not  more  than  three 
doses  given  in  twenty-four  hours.  As  soon  as  the  diagnosis  is  made, 
if  the  case  is  of  rheumatic  origin  it  is  advisable  to  begin  with  the  sali- 
cylate of  soda  (wintergreen)  or  aspirin,  in  order  to  prevent  an  effu- 
19  289 


290  DISEASES   OF   THE   HEART 

sion  into  the  pericardial  sac.  For  those  under  three  years,  fourteen 
to  twenty  grains  of  the  sahcylate  of  soda  or  aspirin  should  be  given 
daily  with  twice  the  amount  of  the  bicarbonate  of  soda.  As  the 
salicylate  is  liable  to  cause  some  gastric  disturbance,  it  should 
never  be  given,  when  the  stomach  is  empty,  except  in  milk  or  with 
some  other  food ;  four  grains  of  the  salicylate  is  as  much  as  should  be 
given  at  one  time.  After  the  third  year,  larger  doses  may  be  given. 
At  the  tenth  year,  forty  grains  may  be  given  daily  in  divided  doses, 
always  in  solution,  observing  the  same  precautions  as  to  giving  it 
after  meals.  It  is  impossible  and  entirely  unnecessary  in  this 
country  to  give  the  large  doses  of  the  salicylate  which  are  given 
abroad. 

In  delicate  children  and  in  those  in  whom  the  salicylate  is  not 
well  tolerated,  aspirin  may  be  substituted  or  the  salicylate  may  be 
given  by  the  bowel,  using  fifteen  grains  at  a  time,  observing  the 
precautions  of  diluting  it  with  at  least  four  ounces  of  water  and  intro- 
ducing it  through  a  rectal  tube  which  has  been  inserted  at  least 
nine  inches.  The  apparatus  shown  in  Fig.  19  is  a  convenient 
means  of  injecting  the  solution.  It  should  not  be  given  oftener 
than  twice  daily  and  should  immediately  follow  an  irrigation  of  the 
large  intestine.  In  the  comparatively  infrequent  cases  which  occur 
as  complications  of  the  infectious  diseases,  the  salicylate  treatment 
is  not  to  be  advised  unless  there  is  some  suspicion  of  rheumatism 
in  the  case.  The  other  methods  suggested  are  to  be  carried  out, 
with  the  hope  that  the  disease  may  be  controlled.  It  is  in  this 
type  of  case  that  the  ice-bag  is  particularly  serviceable.  In  the 
event  of  the  effusion  becoming  so  excessive  as  to  interfere  with 
the  heart  action,  producing  orthopnea  and  cyanosis  with  feeble, 
irregular  pulse,  operation  on  the  pericardium,  such  as  aspiration,  in- 
cision, and  drainage,  is  to  be  considered,  although  in  the  few  opera- 
tive cases  which  I  have  seen  I  have  not  been  impressed  with  its 
great  usefulness.  On  the  other  hand,  I  have  seen  cases,  in  which 
there  was  an  excessive  accumulation  of  fluid,  recover  under  less 
radical  measures.  When  it  becomes  evident  that  pus  is  present 
in  the  sac,  incision  and  drainage  may  be  attempted,  as  the  case 
will  surely  be  fatal  if  the  usual  methods  are  pursued. 

ACUTE  ENDOCARDITIS 

Endocarditis  is  seen  more  frequently  between  the  ages  of  three 
and  ten  years  than  at  any  other  period  of  childhood.  In  probably 
95  percent  of  the  cases  it  is  of  rheumatic  origin.  It  may  occur  as 
a  complication  of  diphtheria,  scarlet  fever,  or  any  other  of  the  in- 
fectious diseases.  In  two  of  my  cases  it  was  associated  with  a  severe 
grippe  infection.  When  due  to  rheumatism,  there  may  be  other 
manifestations  of  the  disease,  or  the  endocarditis  may  be  the  only 
active  evidence  of  rheumatism.     The  patient,  on  close  questioning 


ACUTE    ENDOCARDITIS  29! 

as  to  his  personal  history,  will  usually  give  evidence  of  a  rheu- 
matic tendency  in  previous  attacks  of  rheumatism,  frequent  anginas, 
tonsillitis,  chorea,  or  growing  pains,  or  there  may  be  a  family  history 
of  rheumatism. 

Treatment. — Rest  in  Bed. — Whatever  the  nature  of  the  infection, 
one  rule — that  regarding  quiet  and  rest — must  be  followed  in  all.  The 
child  must  remain  in  a  recumbent  position  in  bed,  the  bedpan 
being  used  to  receive  the  discharges.  The  heart  must  be  given 
as  httle  work  to  do  as  possible.  The  use  of  the  arms  and  the 
hands  should  be  discouraged,  particularly  early  in  the  attack,  as  it 
is  at  this  time  that  the  greatest  damage  is  done  to  the  heart. 
Reaching  from  the  bed  to  the  floor  or  to  the  table  or  chairs  should 
be  forbidden. 

Diet. — The  diet  should  be  largely  of  fluids,  administered  in  com- 
paratively small  amounts,  at  intervals  more  frequent  than  in 
health.  The  bowels  should  move  once  daily.  If  a  laxative  is 
necessary,  a  saline  should  be  given.  A  Seidlitz  powder  or  mag- 
nesium citrate  is  usually  effective.  Distention  of  the  stomach, 
whether  by  gas  or  by  food,  causes  pressure  on  the  heart  and  increases 
its  labor.  It  is  my  custom,  in  these  cases,  to  give  five  feedings 
in  twenty-four  hours,  and  not  more  than  eight  ounces  at  a  feeding. 
Four  ounces  of  milk  with  four  ounces  of  gruel  (see  formula  No.  2) 
with  zwieback  or  toast,  is  the  usual  means  of  feeding.  In  order  to 
vary  the  diet,  a  weaker  gruel,  No.  i,  flavored  with  an  ounce  or  two 
of  chicken  or  mutton  broth,  may  be  given,  or  a  gruel  of  the  same 
strength  may  be  given  plain,  with  sufficient  salt  to  make  it  palatable. 
As  the  case  progresses,  and  the  child  improves,  eggs,  bread  and  but- 
ter, stewed  fruit,  poultry,  fish,  and  plain  puddings  may  be  added 
to  the  diet.  With  the  freer  feeding,  the  number  of  meals  should  be 
reduced. 

The  Ice-hag. — A  screw-top  ice-bag,  half  filled  with  chopped  ice, 
is  placed  over  the  heart  and  it  should  be  our  object  to  keep  it  on 
continuously.  Children  frequently  become  restless  and  irritable 
under  this  constant  application  of  the  ice,  and  in  such  instances  it 
may  be  left  off  occasionally  for  from  one-half  hour  to  one  hour. 

Drugs. — In  endocarditis  following  diphtheria  or  the  exanthemata, 
the  use  of  drugs  is  of  little  benefit;  even  the  salicylates  seem  to 
have  no  beneficial  effect  upon  these  patients.  For  the  excessive 
rapidity  of  the  heart  action  which  is  sometimes  noted,  the  tinc- 
ture of  strophanthus  is  more  effective  than  any  other  drug.  Two 
drops  may  be  given  at  intervals  of  from  three  to  six  hours  to 
children  from  five  to  ten  years  of  age.  If  there  is  much  excitability 
and  restlessness,  codein  \  grain,  or  eight  grains  of  sodium  bromid 
may  be  given  at  sufficiently  frequent  intervals  to  control  the 
condition.  While  every  case  of  non-rheumatic  endocarditis  is  serious 
as  regards  its  possibilities  for  permanent  damage,  not  every  case,  by 


292  DISEASES  OF   THE  HEART 

any  means,  is  of  sufficient  severity  to  demand  other  treatment  than 
the  ice-bag,  rest,  and  an  easily  digested  diet.  It  is  often  the  milder 
cases  that  give  us  the  gravest  sequelae,  on  account  of  the  lack  of 
objective  symptoms.  For  this  reason  it  is  difficult  to  make  parents 
appreciate  the  gravity  of  the  disease,  and  the  child  is  given  liberties 
which  should  never  be  allowed. 

Anti-rheumatic  Treatment. — Every  case  of  endocarditis,  under  my 
care,  which  is  not  directly  associated  with  one  of  the  infectious  diseases, 
is  considered  and  treated  as  though  it  were  rheumatism,  which,  as  pre- 
viously mentioned,  it  almost  invariably  is.  Sodium  salicylate  and  so- 
dium bicarbonate  are  early  brought  into  use.  For  a  child  of  from  five 
to  ten  years  of  age,  from  three  to  five  grains  of  sodium  salicylate  are 
given  after  each  feeding,  five  times  daily,  with  an  equal  quantity 
of  sodium  bicarbonate.  The  drugs  may  be  given  in  capsules  or 
in  solution.  If  the  sodium  salicylate  is  not  well  borne  by  the  stomach, 
aspirin  mav  be  given  in  equal  dosage.  The  salicylate  should  be 
given  with  occasional  intermissions  of  a  day  or  two,  until  the  urgent 
symptoms,  such  as  fever,  rapid  heart,  and  dyspnea  have  subsided. 
The  dosage  should  then  be  varied,  ten  grains  being  given  daily  for 
five  days  out  of  fifteen.  A  child  who  has  once  had  rheumatic 
endocarditis  should  be  kept  under  close  observation  and  the  parents 
warned  as  to  the  possibilities  of  a  second  attack. 

Illustrative  Cases. — In  a  private  case  in  spite  of  anti- rheumatic 
treatment,  during  the  intervals,  four  distinct  attacks  have  occurred 
during  the  past  five  years.  A  dispensary  patient  at  the  New  York 
Polyclinic  had  his  first  attack  when  four  years  of  age.  So  prominent 
was  his  rheumatic  tendency  that  during  the  next  four  years,  regard- 
less of  active  anti-rheumatic  treatment  and  a  careful  diet  in  the  inter- 
vals, he  had  eight  distinct  attacks  of  endocarditis  and  died  from  the 
heart  involvement  in  his  eighth  year.  There  were  other  manifesta- 
tions of  rheumatism  in  his  case,  and  on  both  sides  the  family  for 
several  generations  had  been  markedly  rheumatic. 

Recurrence. — Inasmuch  as  a  recurrence  is  very  probable,  the 
patient  should,  even  while  in  apparent  health,  have  the  benefit  of 
a  restricted  diet,  being  allowed  red  meat  but  twice  a  week  and 
a  minimum  amount  of  sugar.  During  five  days  out  of  each  month, 
he  should  receive  ten  grains  of  sodium  salicylate  and  ten  grains  of 
sodium  bicarbonate,  daily.  This  scheme  of  medication  should  be 
continued  for  at  least  two  years,  and  much  longer  if  the  patient 
shows  anv  rheumatic  tendency,  such  as  pains  in  the  legs  or  repeated 
attacks  of  tonsillitis.  As  to  the  length  of  time  during  which  absolute 
rest  in  bed  is  to  be  enjoined,  every  case  must  be  decided  for  itself. 
The  time  in  bed  for  my  primary  cases  is  from  six  weeks  to  three 
months.  In  one  case,  that  of  a  boy  who  had  had  a  very  severe 
second  attack,  walking  was  not  allowed  for  six  months,  the  patient 
using  a  wheel-chair  instead. 

The  rapidity  of  the  heart's  action  is  the  best  means  of  deciding 


MALIGNANT   ENDOCARDITIS.      MYOCARDITIS  293 

when  the  patient  shall  be  allowed  to  walk.  In  a  case  of  moderate 
severity,  the  heart's  action,  which  has  been  rapid,  140  to  160,  gradu- 
ally becomes  less  frequent.  The  temperature,  perhaps,  continued  for 
only  a  week  or  ten  days. 

Convalescence. — When  the  pulse-beat  is  reduced  to  100,  which  is 
not  to  be  expected  earlier  than  from  the  fourth  to  the  sixth  week,  the 
patient  is  allowed  to  sit  in  a  reclining  chair.  Previous  to  this,  while  in 
bed,  he  is  gradually  accustomed  to  an  elevation  of  the  head  by  the 
addition  of  an  extra  pillow  for  an  hour  or  more  daily.  The  patient  is 
allowed  greater  freedom  when  it  is  found  that  he  can  be  indulged  in 
it,  and  the  heart  kept  below  the  100  mark.  The  above  scheme  of 
management  may  seem  unnecessarily  severe,  but  we  must  remember 
the  importance  of  the  heart  in  the  economy,  and  see  to  it  that  if 
the  patient  cannot  have  a  perfectly  sound  heart,  it  shall  be  damaged 
as  little  as  possible.  It  thus  becomes  a  question  of  observing  every 
precaution  that  will  tend  toward  the  best  possible  outcome,  no 
matter  how  drastic  such  requirements  may  be. 

MALIGNANT  ENDOCARDITIS 
MaHgnant  or  septic  endocarditis  is  rare  in  children.  I  have 
seen  but  three  proved  cases.  One  occurred  with  scarlet  fever, 
one  with  diphtheria,  and  one  followed  what  had  apparently  been 
a  tonsillitis.  In  this  there  was  an  irregular  intermittent  type  of 
temperature  with  gradually  increasing  prostration  and  emaciation. 
In  one  case  the  temperature  frequently  reached  105°  F.  A  systolic 
murmur  was  present  in  two  cases,  apparently  from  the  onset;  in 
the  other  case  it  appeared  three  days  before  death,  and  until  this 
sign  developed,  a  diagnosis  was  not  made.  The  cases  were  all  fatal. 
I  know  of  no  treatment  that  is  of  value  other  than  in  meeting  the 
symptoms  as  they  arise,  with  hypodermatic  stimulation,  suitable 
nutrition,  and  antipyretic  measures  applied  to  the  skin  in  the  form 
of  cool  packs  with  rest  in  the  recumbent  position. 

MYOCARDITIS 

Myocarditis  of  a  mild  degree  is  probably  of  much  more  frequent 
occurrence  than  is  ordinarily  supposed.  It  may  be  associated  with 
inflammatory  conditions  of  the  endocardium  or  pericardium.  It  is 
not  here,  however,  that  it  necessarily  occurs  in  its  most  severe 
form.  The  myocardium  is  most  apt  to  become  involved  as  a  result 
of  bacterial  invasion  of  the  heart  muscle  in  cases  of  grave  sys- 
temic toxemia,  particularly  after  scarlet  fever,  diphtheria,  or 
pneumonia. 

Doubtless  not  a  few  of  the  cases  which  show  marked  irregularity 
of  the  heart  action, with  attacks  of  syncope  and  cyanosis  following  or 
associated  with  the  above  diseases,  are  due  to  a  myocarditis.  Often- 
times the  condition  is  thought  to  be  a  neuritis.     Auscultation  aids  us 


294  DISEASES   OF   THE   HEART 

very  little  in  the  diagnosis.  There  usually  will  be  a  weakened  first 
sound,  but  this  may  occur  without  degenerative  changes  in  the  heart 
muscle.  Persistent  irregularity,  with  or  without  a  tendency  to  rap- 
idity, during  the  early  convalescence  after  the  acute  disease  has  sub- 
sided, is  one  of  the  first  indications  of  the  presence  of  myocarditis.  It 
is  often  most  difficult  to  judge  accurately  of  the  heart  action  of  a 
child  when  he  is  awake,  because  of  the  excitement  and  the  resist- 
ance which  the  physician's  presence  may  occasion.  Cases  in  which 
myocarditis  is  suspected  should  be  examined  during  sleep,  as  to 
the  rapidity  and  regularity  of  the  heart.  The  trained  nurse's  report 
as  regards  matters  of  this  nature  is  not  always  to  be  taken  as  clinical 
evidence.  Persistent  irregularity  of  the  pulse,  as  before  stated,  is 
the  earliest  sign  of  this  very  grave  disease,  and  when  pronounced 
and  when  the  irregularity  continues  during  sleep,  with  cerebral 
complications  excluded,  the  fact  must  be  appreciated  that  the 
child's  life  is  hanging  by  a  slender  thread.  There  are  few  more 
harrowing  experiences  than  to  have  a  child,  when  apparently  pro- 
gressing satisfactorily  on  the  road  to  recovery  after  a  serious  illness, 
die  in  an  attempt  to  reach  a  toy  or  while  assisting  in  putting  on 
his  clothing. 

Treatment. — Rest  in  Bed. — When  the  condition  of  myocarditis 
follows  even  a  mild  attack  of  one  of  the  infectious  diseases,  the  invar- 
iable rule  of  absolute  heart  rest,  which  I  consider  the  most  important 
feature  in  the  treatment,  must  be  insisted  upon.  The  patient, 
whether  in  hospital  or  in  private  practice,  is  not  allowed  to  sit  up  or 
even  to  raise  his  head  from  the  pillow ;  a  trained  nurse  is  kept  con- 
stantly with  him,  so  that  he  may  be  read  to  and  thus  entertained 
while  physical  exertion  is  prevented.  The  child  is  permitted  to  use 
his  arms  only,  to  play  with  simple  light  toys,  all  other  exertion 
being  prohibited.  Other  than  the  recumbent  position,  quiet,  a  daily 
bowel  evacuation,  and  easily  digested  food,  given  in  small  quanti- 
ties, little  treatment  is  required.  It  is  important  to  keep  the 
stomach  free  from  distention  with  either  gas  or  food.  I  prefer  small 
quantities  of  nourishment  at  frequent  intervals  to  large  quantities  of 
food  at  the  usual  meal-time. 

Drugs. — In  more  severe  cases  with  cyanosis  and  dyspnea  a  hypo- 
dermic loaded  with  strychnin  5^0  grain  and  digitalis  j\r)  grain  is 
kept  at  the  bedside  constantly.  In  one  of  my  cases  following  scar- 
let fever,  so  urgent  were  the  symptoms  that  three  physicians  were 
engaged  for  several  days,  each  being  for  eight  hours  daily  at  the 
bedside,  in  addition  to  the  two  trained  nurses,  each  of  whom  was 
doing  twelve  hours'  duty.  My  cases  have  all  been  given  strychnin 
with  the  thought  of  a  possible  associated  involvement  of  the  cardiac 
ganglion.  Further  and  obviously,  certain  portions  of  the  heart 
muscle  remain  free  from  the  degenerative  process  and  may  be  favor- 
ably influenced  by  the  strychnin.     For  a  child  one  year  of  age  ^i 7 


MYOCARDITIS  295 

grain  may  be  given  three  times  daily.  From  the  first  to  the  third 
year,  ^i^  to  j^^  grain  may  be  given  four  times  daily.  After  the  third 
year  the  dose  is  subject  to  considerable  variation,  the  amount  depend- 
ing upon  the  urgency  of  the  case.  Ordinarily  from  J-  to  y^u  grain 
may  be  given  four  times  a  day.  If  the  case  is  very  urgent  and  the 
strychnin  appears  to  improve  the  heart  action,  it  may  be  given  to 
the  point  of  producing  its  physiologic  effects,  such  as  fibrillary 
twitching  of  the  muscles  of  the  face  and  the  backs  of  the  hands. 
Nitroglvcerin  should  not  be  used.  Digitalis  is  rarely  given  to  young 
children,  as  it  is  very  apt  to  disturb  the  digestion  if  long  continued ; 
temporarily  in  older  children,  it  may  be  used  with  advantage.  A 
child  from  five  to  ten  years  of  age  may  be  given  from  three  to  four 
drops  daily  well  diluted  with  water  and  preferably  after  meals.  The 
tincture  of  strophanthus  may  be  of  more  service  here  than  is  any 
other  drug.  It  will  be  found  particularly  useful  in  those  cases  in 
which  there  is  a  tendency  to  rapidity  of  the  heart  action.  A  child 
one  year  of  age  may  be  given  one  drop  every  two  hours  in  the  twenty- 
four  ;  from  the  first  to  the  third  year,  from  one  to  two  drops  at  two- 
hour  intervals;  from  the  third  to  the  tenth  year,  from  two  to  four 
drops  mav  be  given  at  intervals  of  from  two  to  three  hours.  The 
tendency  of  mvocarditis  in  children  is  toward  recovery.  How  long 
each  case  will  require  strict  observation,  and  how  long  the  treatment 
will  ultimatelv  need  to  be  continued,  must  be  determined  by  each 
individual  case.  One  thing  to  be  remembered,  according  to  my 
cases,  is  that  the  child  either  dies  suddenly  or  makes  a  complete  re- 
covery, so  that  as  to  treatment  it  is  better  to  err  on  the  side  of 
caution. 

Convalescence. — I  have  found  it  safe  in  a  very  few  instances  to 
allow  the  child  to  sit  up  after  six  weeks.  In  the  very  severe  case 
above  referred  to,  it  was  not  safe  for  the  patient  to  sit  up  in  bed 
until  the  end  of  the  third  month,  and  he  was  not  allowed  to  walk 
until  the  end  of  the  fourth  month.  He  was  under  observation  for 
one  year,  when  he  was  discharged,  and  has  remained  well  during  the 
two  years  which  have  since  elapsed.  At  the  present  time  there  is  no 
evidence  whatever  of  his  former  illness.  A  safe  rule  to  follow  is  to 
keep  the  patient  in  bed,  as  long  as  the  rapidity  and  irregularity  of 
the  heart  exist.  When  the  heart  action  in  the  recumbent  position 
is  apparentlv  normal,  the  patient  mav  be  allowed  to  have  his  head 
raised  bv  an  additional  pillow.  In  this  way  the  head  and  shoulders 
are  graduallv  raised  day  by  day,  carefully  watching  the  effect  upon 
the  heart.  Progress  is  thus  made  toward  sitting  up  in  bed,  under 
careful  supervision,  until  it  is  demonstrated  that  it  causes  no  un- 
favorable influence  on  the  heart  muscle.  In  the  same  way,  standing 
and  walking  are  gradually  begun.  Following  out  this  careful  method 
of  heart  rest  and  being  governed  solely  by  the  heart  action  which 
indicates  the  heart  power,  I  have  seen  apparently  hopeless  cases  re- 


296  DISEASES    OF    THE   HEART 

cover  completely.     Whether  fibrous  changes  are  present  which  may 
have  a  later  influence,  there  is,  of  course,  no  means  of  knowing. 

CHRONIC  VALVULAR  DISEASE  OF  THE  HEART 

The  most  important  feature  to  keep  in  mind  in  connection  with 
valvular  disease  of  the  heart  in  children  is  the  source  of  the  disease. 
The  fact  that  in  a  large  proportion  of  the  cases  it  is  due  to  rheumatic 
endocarditis,  and  that,  when  endocarditis  has  once  existed,  it  is  very 
liable  to  return,  are  points  not  to  be  forgotten;  so  that  our  first  step 
in  the  management  of  valvular  defects  is  to  discover  the  cause,  and, 
if  it  is  found  to  be  of  rheumatic  origin,  it  should  be  explained  to  the 
parents  that  other  attacks  of  endocarditis  are  very  Hable  to  occur, 
unless  means  are  used  for  their  prevention.  In  the  absence,  then, 
of  a  history  of  endocarditis  in  association  with  pneumonia,  diphtheria, 
or  scarlet  fever,  which  in  my  experience  has  been  of  rare  occurrence, 
it  is  assumed  that  the  valvular  lesion  is  of  rheumatic  origin,  even 
though  there  may  not  be,  at  the  time,  positive  evidence  of  rheuma- 
tism elsewhere.  In  not  a  few  of  these  children  with  cardiac  disease 
without  a  history  of  acute  rheumatism,  there  will  be  a  history  of 
tonsillitis,  angina,  coryza,  asthmatic  bronchitis,  or  chorea — all  show- 
ing recurrent  tendencies.  The  patients  will  often  be  found  to  have 
a  rheumatic  or  gouty  ancestry,  and  not  infrequently  they  themselves 
will  be  heavy  eaters  of  red  meat  and  sugars. 

Treatment. — Our  first  step,  then,  in  the  management  is  so  to 
regulate  the  life  as  to  prevent  a  recurrence  of  the  heart  involvement. 
With  this  end  in  view,  it  is  directed  that  meat  be  given  the  child  but 
once  every  second  day,  and  that  sugar  be  given  in  great  modera- 
tion. A  tub-bath  followed  by  a  dry  rub  is  given  daily.  The 
bowels  are  not  allowed  to  become  constipated,  and  moderate  exer- 
cise is  encouraged. 

Drugs  Advised. — For  five  days  out  of  each  month,  the  patient 
is  given,  after  meals,  five  grains  of  salicylate  of  soda  (wintergreen) 
and  ten  grains  of  bicarbonate  of  soda.  This  with  the  low  meat  and 
low  sugar  diet  is  usually,  but  not  invariably,  sufficient  to  prevent  a 
recurrence.  In  a  boy  who  has  been  under  my  care  for  several  years, 
and  who  has  had  three  distinct  attacks  of  endocarditis,  I  am  obUged 
to  give  the  above  treatment  for  five  days  with  but  ten  days'  inter- 
mission. This  has  been  continued  for  eighteen  months,  during  which 
time  the  heart  has  not  been  affected.  During  the  past  year  there  has 
been  no  tonsillitis,  while  previously  he  had  had  severe  attacks  every 
month  or  two.     Both  sides  of  the  family  are  markedly  rheumatic. 

Drugs  Used  with  Caution. — The  further  management  of  valv- 
ular disease  depends  to  a  certain  degree  upon  the  location  and 
nature  of  the  lesion.  Right  here  I  would  sound  a  note  of  warn- 
ing: Because  a  child  has  a  cardiac  lesion  he  does  not  neces- 
sarily require   digitalis.      Not  a  Httle   harm  is  done,  in  the  treat- 


CHRONIC    VALVULAR    DISEASE    OF   THE    HEART  297 

merit  of  diseases  in  children,  by  giving  powerful  drugs  when  they 
are  not  indicated.  Too  often  in  heart  disease  the  physician  feels 
his  duty  done  when  he  gives  digitahs.  Many  times  1  have  seen 
children  who,  because  of  some  cardiac  lesion,  were  taking  digitalis 
and  strychnin,  while  at  the  same  time  they  were  suffering  from 
constipation,  recurrent  respiratory  disorders,  and  persistent  indi- 
gestion due  to  dietetic  errors,  all  of  which  had  escaped  the  attention 
of  the  physician. 

Prognosis. — Under  proper  management,  if  begun  early,  the  prog- 
nosis in  valvular  disease  in  children  is  good.  The  heart  nutrition  and 
compensation  in  children  are  usually  most  satisfactory.  I  have  several 
now  under  my  care,  in  whom  grave  cardiac  disease  exists,  without  any 
disturbance  of  any  nature  whatever  which  is  evident  to  those  who 
come  in  contact  with  the  children.  In  neglected  cases  the  outlook 
is  bad.  This  is  due,  first,  to  the  tendency  of  the  endocarditis  toward 
recurrence;  and,  second,  to  our  neglect  to  control  the  activities  of  the 
child.  The  prognosis  is  better  when  the  insufficiency  involves  the 
mitral  valves  alone.  In  such  cases  the  activities  need  be  but  little 
curtailed;  in  fact,  the  patient  is  encouraged  to  indulge  in  outdoor 
exercise,  but  competition  in  games  requiring  unusual  exertion,  tests 
of  speed  or  endurance  of  any  nature,  such  as  running  and  racing,  is 
forbidden.  When  the  patient  is  old  enough,  swimming,  the  bicycle, 
horseback-riding,  and  golf  are  advised.  In  boys,  when  the  tobacco 
and  alcohol  age  arrives  they  must  be  told  the  dangers  attending  the 
use  of  either  and  both  must  be  forbidden.  Girls  with  mitral  insuffi- 
ciency must  be  warned  against  excessive  dancing,  rope-jumping, 
tight  lacing,  and  indiscriminate  eating.  With  both,  rational  exercise 
is  beneficial. 

When  the  aortic  valves  are  involved  either  in  insufficiency  or 
stenosis,  or  when  there  is  a  considerable  degree  of  mitral  stenosis, 
the  child's  activities  should  be  considerably  limited.  Under  these 
conditions,  with  a  view  to  the  future,  regardless  of  the  existing  satis- 
factory compensation,  I  forbid  the  bicycle,  swimming,  dancing, 
baseball,  or  any  sport  or  game  which  may  call  for  much  physical  effort. 
The  nature  of  the  disease  should  be  fully  explained  to  the  parent  and 
to  the  patient,  when  he  is  old  enough  to  understand  it,  so  as  to  secure 
his  hearty  cooperation,  not  only  as  related  to  his  activities,  which, 
of  course,  is  important,  but  parents  should  be  told  particularly 
that  a  tonsillitis  or  an  angina  is  a  danger-signal,  and  that  the  sali- 
cylates are  to  be  brought  into  use  at  once,  even  before  the  physician 
is  summoned.  A  diet  of  plain  nutritious  food,  with  nothing  between 
meals,  is  a  very  important  feature  in  the  treatment  of  heart  disease 
in  children.  Ordinarily  it  is  not  well  to  talk  over  the  child's  ailments 
with  him  or  in  his  presence ;  in  cardiac  disease,  however,  I  explain  to 
him  as  clearly  as  possible  the  nature  of  the  illness,  and  insist  that  cer- 
tain measures,  particularly  such  as  relate  to  restriction  of  activity, 
shall  be  carried  out  indefinitelv.     I  find  in  this  way  that  better  co- 


298  DISEASES    OF    THE    HEART 

operation  on  the  part  of  the  patient  is  secured  than  if  he  were  simply 
given  a  hst  of  dogmatic  "don'ts."  It  is  my  custom,  further,  in 
those  who  show  aortic  involvement  or  mitral  stenosis,  to  advise  what 
is  known  as  "heart  rest."  Every  day  after  the  midday  meal,  with 
clothing  off  or  loosened,  the  child  is  made  to  rest  in  a  recumbent 
position  for  at  least  one  hour.  During  this  time  he  may  sleep  or 
read,  as  best  suits  his  individual  taste. 

Medication. — As  most  of  the  cases  of  valvular  disease  in  children 
are  of  rheumatic  origin,  it  will  be  found  that  the  majority  of  the 
patients  are  suffering  from  anemia,  usually  in  mild  degree.  All  the 
benefits  of  nutrition,  fresh  air,  and  regularity  in  living  referred  to 
under  Tardy  Malnutrition  (page  158)  should  be  afforded  these 
children.  Iron  alone  or  with  arsenic  is  of  some  value  here  when 
given  with  a  suitable  diet.  A  method  often  followed  is  to  give,  for 
five  days,  the  salicylate  and  bicarbonate  of  soda  already  referred  to; 
for  fifteen  days  iron  and  arsenic,  with  the  remaining  ten  days  of 
each  month  free  from  medication,  unless  cod-liver  oil  is  well  borne, 
in  which  case  it  is  usually  given  in  combination  with  the  extract 
of  malt.  Should  the  patient  be  of  an  age  when  a  capsule  can  be 
swallowed,  the  following  is  given: 

I^.      Liquoris  potassii  arsenitis gtt.  xc 

Extract!  ferri  pomati Rr.  x 

Quininae  bisulphatis 3  j 

M.  ft.  capsulae  No.  xxx. 

Sig. — Take  one  after  each  meal. 

If  the  iron  produces  constipation,  from  one-third  to  one-half 
grain  of  the  extract  of  cascara  may  be  added  to  each  capsule. 

Heart  Stimulants. — Aside  from  such  tonic  medication,  as  far  as 
concerns  the  heart  per  se,  drugs  should  not  be  given  unless  com- 
pensation fails.  This  may  take  place  temporarily,  regardless  of  the 
nature  of  the  lesion,  after  some  forbidden  exercise,  or  during  an 
acute  illness  sufficient  to  produce  prostration,  and  permanently,  in 
those  cases  which  for  any  reason  do  badly.  In  the  event  of  defec- 
tive compensation  and  dilatation,  the  child  should  be  kept  in  bed 
until  the  normal  heart  action  is  restored,  or  until  it  is  demonstrated 
that  the  aid  of  heart  stimulants  is  required.  In  these  cases,  particu- 
larly in  those  of  the  latter  type  when  there  is  a  rapid,  irregular  pulse, 
difficult  breathing  on  excitement,  and  dropsy,  the  time-honored 
remedy,  digitalis,  is  to  be  brought  into  use.  In  children  I  prefer  to 
use  the  tincture.  For  a  child  from  five  to  ten  years  old,  from  three 
to  five  drops  may  be  given  after  meals,  three  or  four  times  daily. 
The  drug,  because  of  its  well-known  irritant  effects  upon  the  stomach, 
should  be  given  considerably  diluted.  Its  beneficial  effects  will  be 
noticed  first  in  the  relief  of  the  dyspnea,  the  pulse  becoming  regular 
and  of  increasing  volume,  and  later  in  the  increased  secretion  of 
the  kidneys  and  the  disappearance  of  the  edema.  The  amount  of 
digitalis  given  should  be  reduced  as  soon  as  the  condition  of  the 


CONGENITAL  HEART  DISEASE — ABUSE  OF  HEART  STIMULANTS      299 

patient  will  allow,  but  it  should  be  continued  for  a  considerable  time 
after  he  is  up  and  about.  The  only  contraindication  to  the  use  of 
digitalis  in  children  is  its  effect  upon  the  stomach.  This  is  often  so 
unfavorable  that  it  causes  a  loss  of  appetite,  in  which  case  its  ad- 
ministration should  be  discontinued.  In  this  event  the  tincture  of 
strophanthus,  which  is  referred  to  repeatedly  in  this  work,  as  a  heart 
stimulant,  may  be  substituted  in  the  same  doses.  In  case  a  cardiac 
stimulant  is  necessary  for  a  considerable  time  or  permanently,  I 
have  had  satisfactory  results  by  alternating  the  digitalis  with  the 
strophanthus,  giving  each  for  five  days.  The  child,  however,  who 
requires  constant  cardiac  stimulation  promises  but  little  for  the 
future,  and  few  of  my  cases  have  survived  the  eighteenth  year. 

CONGENITAL  HEART  DISEASE 
The  majority  of  the  cases  of  congenital  heart  defects  which  have 
come  under  my  observation  have  died  before  the  second  year,  usually 
from  some  intercurrent  disease.  Patients  who  pass  this  period  of 
life  rarely  reach  the  sixth  year.  When  the  child  becomes  active  in 
physical  exercise,  such  as  in  climbing  stairs  and  in  play,  dilatation  of 
the  right  heart  results.  In  two  of  my  cases  presenting  such  a 
course  death  took  place  suddenly  in  an  attack  of  orthopnea  and 
cyanosis.  It  may,  however,  be  delayed  until  the  child  develops  one  of 
the  infectious  diseases,  such  as  measles  or  scarlet  fever  or  diphtheria. 
But  little  is  to  be  said  as  to  treatment.  During  the  first  year  or  two 
no  treatment  is  necessary.  Later,  if  the  child  survives,  rest,  an 
easily  digested  diet,  morphin  or  other  sedatives,  with  cardiac  stimu- 
lation hypodermically,  may  give  symptomatic  relief. 

ABUSE  OF  HEART  STIMULANTS  ■ 
Probably  the  heart  stimulants,  such  as  alcohol,  strvchnin,  digi- 
talis, and  strophanthus,  are  given  unadvisedly  with  greater  fre- 
quency to  children  than  is  any  other  form  of  medication.  If  given 
needlessly,  they  are  harmful  indirectly,  in  that  when  the  time  for  their 
use  really  arrives,  the  system  having  become  accustomed  to  their 
action,  less  benefit  is  derived  from  them.  All  forms  of  cardiac 
stimulants  are  of  temporary  value  only.  In  some  patients  the  stimu- 
lant effect  of  drugs  will  be  exhausted  quicker  than  in  others.  The 
common  practice  of  giving  heart  stimulants,  simply  because  a  child 
has  pneumonia,  typhoid  fever,  or  diphtheria,  is  a  very  bad  one.  For 
giving  these  drugs  to  the  best  advantage,  there  should  be  one  special 
indication  and  only  one — the  evidence  of  heart  weakness.  A  very 
rapid  heart,  above  150  beats  to  a  minute  in  a  sleeping  child,  may 
require  help,  for  otherwise  it  may  become  exhausted  because  of  the 
rapidity  of  its  action.  Pronounced  weakness  of  the  first  sound  and 
the  accentuation  of  the  second  sound  call  for  stimulation.  When 
the  heart  action  is  irregular  or  intermittent,  and  when  cyanosis  de- 
velops, heart  stimulants  are  called  for. 


CONTAGIOUS  DISEASES 

CARE  TO  BE  EXERCISED  BY  THE  PHYSICIAN  IN  VISITING 
CONTAGIOUS  DISEASES 

As  a  rule,  physicians  in  attendance  upon  contagious  diseases  are 
grossly  negligent  as  to  the  use  of  proper  precautions  against  the 
possibility  of  themselves  becoming  mediums  of  infection.  The  phy- 
sician who,  without  washing  his  hands,  makes  a  practice  of  going 
from  a  child  ill  with  diphtheria  or  scarlet  fever  to  patients  otherwise 
afflicted,  is  an  element  of  great  danger  in  any  community.  While 
properly  caring  for  a  patient,  close  contact  is  necessary,  particularly 
in  the  treatment  of  throat  and  nose  cases.  Not  only  his  hands,  but 
his  clothing  as  well,  may  become  infected.  Therefore,  before  enter- 
ing the  room  in  which  there  is  a  contagious  disease  the  physician 
should  remove  his  coat  and  his  cuffs,  if  detachable,  and  turn  up  to 
the  elbows  the  sleeves  of  his  shirt.  If  a  clean  gown  is  not  available, 
an  ordinary  clean  bed-sheet  will  answer,  this  being  so  adjusted  as  to 
protect  the  clothing,  and  held  in  position  by  two  or  three  safety-pins. 
My  custom,  when  attending  contagious  diseases,  is  to  keep  in  an  ad- 
joining room  or  closet  a  gown  which  I  wear  while  in  the  sick-room. 

After  leaving  the  patient  the  physician  should  thoroughly  wash 
his  hands  with  hot  water  and  soap,  outside  the  sick-room  if  possible. 
An  excuse  may  be  offered  for  not  wearing  the  gown,  but  there  is  none 
for  not  removing  the  coat  and  cuffs,  nor  for  the  failure  to  use  the 
sheet,  as  suggested ;  and  none  for  the  failure  thoroughly  to  wash  the 
hands  after  leaving  the  patient. 

QUARANTINE 
The  isolation  of  those  ill  with  contagious  diseases  is  an  absolute 
necessity  for  the  protection  of  others.  While  it  is  advisable  in  cases 
of  scarlet  fever  to  remove  from  the  house  children  who  have  not  had 
the  disease,  and,  in  the  event  of  diphtheria,  all  children,  regardless  of 
previous  attacks,  such  removal  is  often  impossible.  It  then  becomes 
our  duty  to  establish  such  a  quarantine  as  will  be  effective  in  pre- 
venting the  transmission  of  the  disease.  In  order  to  do  this,  the 
child  and  the  attendant  must  not  come  in  contact  with  other  mem- 
bers of  the  family,  whether  children  or  adults.  If  the  residence  is  a 
citv  or  a  country  house,  one  or  two  rooms  on  the  top  floor  are  selected 
for  the  patient,  the  room  from  which  he  was  removed  being  carefully 
cleaned  and  disinfected.  If  the  family  occupy  an  apartment,  an 
effective  isolation  is  more  difficult,  but  is  by  no  means  impossible. 

300 


QUARANTINE  30I 

In  such  circumstances  the  room  or  rooms  must  be  as  remote  as  pos- 
sible from  the  other  hving-rooms.  The  room  in  which  the  child  is 
placed  is  prepared  for  the  patient  according  to  the  instructions  laid 
down  on  page  43.  Not  only  should  the  attendant  not  come  in  direct 
contact  with  other  members  of  the  family,  but  there  must  be  no  in- 
direct contact  through  dishes,  feeding  utensils,  clothing,  or  bed-linen. 
The  dishes,  knives,  forks,  and  spoons  should  be  placed  in  boiling 
water  and  in  this  way  sent  to  the  kitchen.  The  clothing,  towels,  and 
bed-linen  should  be  placed  either  in  boiling  water  or  in  a  carbolic 
solution — one  ounce  to  two  gallons  of  water — before  sending  them 
to  the  laundry.  Upon  their  arrival  at  the  laundry  they  should  be 
boiled  at  once.  A  chair  outside  the  door  of  the  sick-room  may  be 
used  as  a  receptacle  for  the  various  necessities  for  the  patient,  which 
are  to  be  removed  only  when  the  person  who  brought  them  is  at  a 
safe  distance. 

Two  isolating  rooms  are  better  than  one,  and  if  there  can  be  a 
connecting  bath-room,  it  is  much  more  agreeable  to  the  occupants. 
If  two  rooms  are  devoted  to  the  patient,  one  is  used  for  day  and 
the  other  for  night  occupancy,  the  unoccupied  room  being  freely 
ventilated  after  the  removal  of  the  child.  Observing  the  above  pre- 
cautions until  the  child  is  well,  I  have  repeatedly  carried  through 
to  successful  convalescence  cases  of  diphtheria  and  scarlet  fever 
while  other  unprotected  children  have  remained  in  the  household 
during  the  entire  illness  without  taking  the  disease. 

An  incident  which  well  demonstrates  the  value  of  proper  quaran- 
tine occurred  at  the  New  York  Infant  Asylum,  Mt.  Vernon,  New 
York,  during  my  service  as  interne  in  that  institution.  The  institu- 
tion was  built  on  the  cottage  plan,  two  wards  in  a  cottage.  A  colored 
child,  an  occupant  of  one  of  the  upper  wards,  was  discovered  to  be 
ill  with  scarlet  fever.  There  was  an  extensive  rash,  considerable 
swelUng  of  the  cervical  glands,  and  the  whole  aspect  of  the  case  was 
that  of  scarlet  fever  at  its  height.  Through  the  negligence  of  an 
orderly,  the  child  had  probably  been  ill  two  or  three  days  before  our 
attention  was  called  to  him;  as  a  consequence,  thirty  other  children 
of  the  ward  had  been  exposed.  In  order  to  prevent  the  spread  of 
the  disease  to  the  other  four  hundred  children,  it  was  decided  to 
quarantine  the  ward  with  its  children  and  the  four  attendants. 
This  was  done.  Twenty-six  children  and  two  women  attendants 
developed  the  disease.  The  quarantine,  on  the  plan  above  sug- 
gested, was  continued  for  ten  weeks.  The  thirty  or  more  children 
on  the  ground  floor  of  the  cottage  remained  there  as  before,  but 
no  other  case  developed  in  the  institution.  In  order  to  prevent  the 
spread  of  the  contagion,  there  was  no  personal  contact  with  those 
outside  of  the  ward,  except  with  the  physician  who  visited  them 
daily,  but  who  always  went  properly  protected  (page  300).  All 
clothing  and  bed-linen  were  boiled  before  leaving  the  ward.     The 


302  CONTAGIOUS   DISEASES 

dishes  and  feeding  utensils  likewise  were  boiled  before  being  sent  to 
the  general  kitchen. 

If  such  isolation  is  possible  in  an  institution  among  the  careless 
and  more  or  less  ignorant,  it  certainly  should  be  equally  effective 
among  the  intelligent,  who  are  most  interested  in  preventing  the 
spread  of  disease. 

When  the  quarantine  is  raised  the  child  should  receive  a  bath  of 
bichlorid  of  mercury  i  :  3000.  If  the  hair  is  cut  short  and  sham- 
pooed with  green  soap,  followed  by  the  bichlorid,  the  disinfection  is 
more  complete. 

DIPHTHERIA 

Diphtheria  is  an  infectious,  contagious  disease  due  to  the  Klebs- 
Loeffler  bacillus.  Its  first  manifestation  is  inflammation,  usually  of  a 
mucous  surface,  with  the  production  of  a  pseudo-membrane.  Any 
of  the  mucous  surfaces  may  be  involved.  Thus,  under  my  own  ob- 
servation, the  process  has  involved  the  nasal  cavities,  the  lips,  the 
mouth,  tonsils,  pharynx,  larynx,  trachea,  and  bronchi.  The  esopha- 
gus was  the  seat  of  the  pseudo-membrane  in  one  case  and  the  con- 
junctiva in  several.  The  rectum  or  the  vagina  may  also  be  the  seat 
of  the  disease.  Constitutional  and  other  symptoms  fairly  character- 
istic rapidlv  follow  the  local  manifestation.  There  is  always  some 
fever,  but  the  temperature  is  usually  low.  Swelling  of  the  glands 
at  the  angle  of  the  jaw  is  an  early  and  important  sign  if  the  throat  is 
involved.  The  breath  in  many  patients  with  diphtheria  has  a  pecu- 
liarly offensive  odor  which  occurs  in  no  other  disease.  By  far  the 
most  frequent  sites  of  the  local  manifestations  are  the  tonsils,  the 
fauces,  and  the  larynx,  the  nasal  cavities  being  more  rarely  involved. 
It  is  not  within  the  province  of  this  book  to  go  into  details  as  regards 
differential  diagnosis  or  description  of  the  various  phases  of  the  dis- 
ease. They  can  be  found  in  any  text-book  on  children's  diseases. 
What  is  particularly  necessary,  in  the  light  of  modern  treatment,  is 
that  the  physician  familiarize  himself  with  the  clinical  picture  of  the 
disease  in  its  various  phases,  so  as  to  be  able  to  recognize  it  regardless 
of  where  or  how  it  appears. 

Antitoxin. — Owing  to  our  increased  knowledge  of  the  etiology 
of  diphtheria  and  since  the  advent  of  the  specific  remedy,  anti- 
toxin, the  disease  has  lost  much  of  its  former  terror.  It  is  still, 
however,  a  considerable  factor  in  the  death-rate  of  all  large  cities. 
This  is  due  to  two  causes:  first,  to  parents  who  fail  to  appre- 
ciate the  possible  dangers  that  may  arise  from  a  sore  throat  and 
who  neglect  to  call  a  physician  early  in  the  illness;  second,  to 
physicians  who  do  not  believe  in  diphtheria  antitoxin,  to  those  who 
timidly  use  it  in  small  doses  late  in  the  disease,  or  to  those  who  wait 
for  positive  clinical  signs  or  a  report  of  a  culture  before  using  it. 
Equally  as  necessary  as  is  the  realization  of  the  value  of  antitoxin. 


DIPHTHERIA  303 

is  the  knowledge  as  to  how  and  when  to  use  it  and  when  to  repeat  it. 
In  many  cases  at  the  beginning  of  the  disease,  when  the  tonsils  alone 
are  involved,  it  is  impossible  without  the  aid  of  the  laboratory  to 
differentiate  diphtheria  from  tonsillitis.  I  have  seen  case  after  case 
in  the  pre-antitoxin  period  in  which  two  or  three  days  were  required 
to  make  a  positive  cUnical  diagnosis.  In  towns  in  which  a  bacterio- 
logic  examination  is  possible  it  is  in  some  instances  safe  to  wait  for  a 
report  from  such  an  examination.  When  in  doubt,  a  safer  rule  to 
follow,  in  those  cases  in  which  there  is  pseudo-membrane  on  the 
tonsils,  is  to  give  antitoxin  at  once.  If  the  case  proves  to  be  a  simple 
tonsillitis  no  harm  will  follow.  I  have  given  full  doses  of  antitoxin 
to  patients  in  whom  we  afterward  learned  there  was  no  diphtheria, 
without  any  unfavorable  results. 

Illustrative  Case. — During  the  past  winter  (1906-1907)  I  was 
called  to  see  a  little  girl  six  years  old  with  a  gray  membranous  patch  on 
the  left  tonsil,  the  size  of  a  thumb-nail.  There  was  a  temperature  of 
101°  F.  The  child  was  complaining  of  feeling  tired  and  seemed 
wretched  generally.  There  was  considerable  difficulty  in  swallowing. 
I  gave  at  once  3000  units  of  antitoxin  and  sent  to  a  private  labora- 
tory a  culture  from  the  throat.  The  report  reached  me  the  next 
morning  that  the  Klebs-Loeffler  bacillus  was  absent.  On  visiting 
the  case  at  this  time  I  found  that  the  membrane  had  extended, 
the  right  tonsil  being  covered.  I  repeated  the  antitoxin,  giving 
3000  units  more,  and  took  another  culture.  This  was  sent  to  another 
private  laboratory.  Again  the  report  was  negative  for  the  Klebs- 
Loeffler  bacillus,  but  the  culture  showed  a  pure  growth  of  the  strep- 
tococcus. The  following  morning  the  throat  began  to  clear,  and  in 
two  days  was  normal.  Clinically  this  case  was  diphtheria.  There 
was  no  scarlatina,  but  there  was  some  swelling  of  the  glands  at  the 
angle  of  the  jaw.  The  child  showed  no  symptoms  whatever  to  indi- 
cate that  antitoxin  had  been  given. 

Necessity  for  Promptness  in  the  Use  of  Antitoxin. — When  there 
is  diphtheria  and  we  wait  for  positive  clinical  signs  or  for  the  report 
of  a  culture,  even  though  but  for  ten  or  twelve  hours,  most  valuable 
time  is  lost,  and  it  is  this  delay  that  is  responsible  for  many  deaths. 
If  there  is  one  thing,  in  addition  to  its  great  usefulness,  that  we  have 
learned  as  to  the  administration  of  antitoxin,  it  is  the  necessity  of 
giving  it  at  the  earliest  possible  moment  in  the  disease  and  of  giving 
it  in  full  doses. 

Dosage. — After  a  large  experience  in  the  use  of  antitoxin  I  am 
convinced  that  it  is  often  given  in  too  small  initial  doses  even  by  many 
famihar  with  its  use.  In  April,  1904,  I  commenced  to  use  larger 
doses,  rarely  giving  less  than  5000  units  at  the  first  injection.  When 
there  is  membrane  on  the  uvula,  the  pillars  of  the  fauces,  or  the  pos- 
terior pharyngeal  wall,  or  in  the  nose,  we  should  never  wait  for  the 
report  of  a  culture,  but  a  full  dose  of  antitoxin  should  be  given  at 


304  CONTAGIOUS   DISEASES 

once.  The  antitoxin  is  to  be  repeated  eight  or  twelve  hours  later  if 
there  is  an  extension  of  the  membrane  or  if  there  is  no  change  in  its 
appearance.  If  the  throat  shows  a  tendency  toward  improvement, 
if  there  is  a  curHng  up  and  loosening  of  the  membrane  at  the  edges,  or 
if  it  has  taken  on  the  granular  appearance  peculiar  to  diphtheritic 
membrane  after  a  full  dose  of  antitoxin,  it  may  be  safe  to  wait  twelve 
hours  longer,  twenty-four  hours  in  all,  before  deciding  whether  a 
repetition  of  the  original  dose  or  a  smaller  one  is  required.  A  dimi- 
nution in  the  nasal  discharge  in  the  nasal  cases,  a  lessening  of  the 
breath  fetor,  a  reduction  in  the  glandular  swelling,  and  a  fall  in  the 
temperature — all  are  indications  of  improvement,  but  the  physician 
should  not  rest  there ;  the  constitutional  improvement ,  the  clearing- 
up  process,  must  be  rapid  and  complete,  and  when  the  case  shows  no 
sign  of  improvement,  more  antitoxin  should  be  given. 

A  child  ill  with  diphtheria  must  be  looked  upon  as  a  child  poisoned ; 
antitoxin  is  the  antidote,  and  every  case  must  receive  enough  of  the 
antidote  to  neutralize  the  poison.  Whether  this  will  be  supplied, 
depends  upon  the  recentness  of  the  infection  when  seen  by  the  physi- 
cian and  upon  his  ability  to  apply  the  remedy.  In  a  recent,  very 
severe  case,  in  a  girl  eight  years  of  age,  16,000  units  were  required  be- 
fore the  disease  yielded.  The  first  injection  was  given  on  the  second 
day  of  the  disease.  In  a  laryngeal  case  in  a  boy  five  years  of  age, 
9000  units  were  given  in  nine  hours. 

Laryngeal  Diphtheria. — If,  during  the  course  of  an  attack  of  diph- 
theria or  in  a  case  which  may  have  been  diagnosed  as  tonsillitis,  the 
voice  becomes  hoarse  and  croupy,  it  is  an  almost  infallible  sign  that 
the  process  has  extended  to  the  larynx,  and  7000  units  of  antitoxin 
should  be  given  without  delay.  If,  after  waiting  eight  hours,  there  is 
no  improvement  in  the  laryngeal  symptoms,  or  if  they  have  increased 
in  severity,  5000  more  units  should  be  given.  Laryngeal  cases  re- 
quire larger  and  more  frequently  repeated  doses  than  do  those  in 
which  the  fauces  alone  are  involved.  Cases  of  laryngeal  diphtheria 
without  .previous  throat  involvement  tax  our  judgment  most  se- 
verely. 

Differential  Diagnosis. — It  is  by  no  means  an  easy  matter  to 
dififerentiate  the  croup  due  to  an  acute  catarrhal  laryngitis  from  that 
due  to  membranous  laryngitis.  The  following  points  have  aided 
me  in  many  instances  in  forming  a  right  conclusion : 

Diphtheritic  Croup.  Catarrhal  Crocp. 

Gradual  onset.  Obstruction   intermittent  with   gradu- 

Obstruction  persistent.  ally  increasing  severity. 

Obstruction    both    to  inspiration  and       Sudden  onset. 

expiration.  Obstruction  to  inspiration,  only. 
Little  or  no  response  to  emesis  or  in-       Response  to  emesis  and  inhalations  and 

halations.  to  sedatives. 
No  response  to  sedatives. 

The  mode  of  onset  is,  of  course,  not  to  be  relied  upon  absolutely 


DIPHTHERIA 


305 


in  differentiation.  Occasionally  the  onset  of  catarrhal  laryngitis  may 
be  gradual  while  that  of  diphtheria  is  sudden.  In  the  consideration 
of  a  great  many  cases,  however,  the  points  of  differentiation  are  of 
sufficient  value  to  warrant  the  attention  which  has  been  given  them. 
A  safe  rule  to  follow,  in  view  of  the  urgent  demand  for  early  injec- 
tions of  antitoxin,  is  the  same  as  in  other  forms  of  diphtheria,  i.  e., 
when  in  doubt,  inject  from  5000  to  7000  units.  From  the  gradual 
cessation  of  the  laryngeal  symptoms  it  is  fairly  safe  to  assume  that 
the  child  is  doing  well,  although  the  breathing  may  not  be  entirely 
free  for  forty-eight  or  seventy-two  hours  after  the  first  injection.     In 


Date 

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28.— Ch.\rt  Showing  the  Effect  of  Antitoxin  upon  the  Temper.^ture  in 

L.\RYNGE.\L     DiPHTHERl.A. 


cases  which  require  intubation,  7000  to  10,000  units  should  be  given 
for  the  first  injection  and  repeated  the  following  day.  According  to 
my  observation,  intubation  cases  require  10,000  to  15,000  units  even 
when  antitoxin  is  used  early,  by  which  we  understand  on  the  second 
or  third  day  of  the  disease.  If  this  amount  or  more  must  ultimately 
be  given,  it  is  advisable  to  give  it  early  in  the  disease.  The  earlier 
the  injection,  the  less  frequent  will  be  the  necessity  for  its  repetition. 
Illustrative  Case. — The  chart  presented  in  Fig.  28  well  show^s  the 
effect  of  antitoxin  upon  the  disease  as  represented  by  the  tempera- 
ture. The  case  was  one  of  a  girl  eight  years  of  age,  who  when  I  first 
saw  her  had  been  ill  for  two  days  with  sore  throat.     At  the  time  the 


3o6  CONTAGIOUS   DISEASES 

uvula,  the  pillars  of  the  fauces,  the  tonsils,  the  soft  palate,  the  post- 
pharyngeal wall,  and  the  nose  were  involved.  Three  thousand  units 
were  given  at  once.  In  a  similar  case  now  I  would  give  from  5000 
to  7000  units.  An  improvement  in  the  physical  condition  of  the 
child  and  in  the  local  process  kept  pace  with  the  temperature,  both 
being  favorably  influenced  by  the  treatment,  but  it  required  9000 
units  of  the  antitoxin  to  counteract  the  effect  of  the  diphtheritic 
poison. 

Antitoxin  in  Non-operative  Cases. — Seventy-one  non-operative 
cases  of  diphtheria  have  been  treated  by  me  with  antitoxin  with 
doses  varying  from  1000  to  16,000  units,  the  former  being  given  in 
one  case  only.  Among  these  cases  one  was  fatal — my  first  and 
only  fatal  non-operative  case.  The  patient  was  given  1000  units 
on  the  fourth  day  of  the  illness.  He  died  on  the  eighth  day.  It  is 
hardly  fair  to  include  this  case  in  the  antitoxin  group,  as  at  that  time 
we  did  not  know  how  to  use  antitoxin  and  therefore  w^ere  more  or  less 
timid,  and  the  serum  was  not  up  to  its  present  high  order  of  efficiency. 
An  early  and  full  dosage  explains  the  above  most  satisfactory  results. 
Nineteen  operative  intubation  cases  were  treated  with  antitoxin,  and 
of  these  sixteen  recovered.  One  of  the  fatal  cases  died  on  the  second 
day  of  the  illness  from  a  complicating  lobar  pneumonia.  Another 
was  seen  in  consultation  on  the  fifth  day,  intubated,  and  given  3000 
units  at  once.  The  child  was  septic  at  the  time  and  died  in  twelve 
hours.  The  remaining  case,  also  seen  in  consultation,  was  intubated 
and  received  3000  units  on  the  fifth  day.  The  antitoxin  was  re- 
peated twice  at  twelve-hour  intervals.  The  child  died  of  heart  failure 
forty-eight  hours  after  the  first  injection.  We  now  know  that  these 
children  should  have  received  at  least  5000,  or  better  10,000,  units  at 
the  first  injection  and  the  dose  repeated  at  eight -hour  intervals. 

In  fourteen  non-operative  cases  in  which  the  injection  was  given 
on  the  first  day  of  the  illness  it  was  necessary  in  but  one  case  to  re- 
peat the  antitoxin  on  the  following  day.  In  all  of  these  cases  the 
throats  were  clear  in  from  thirty-six  to  seventy-two  hours  after  the 
first  injection.  Among  twenty-three  non-operative  cases  injected 
the  second  day,  seven  required  a  second  injection  on  the  third  day, 
and  in  three  of  these  a  third  injection  was  given  on  the  following  day. 
Among  seven  third-day-injection  cases,  two  required  three  injections 
and  two  received  two  injections. 

Late  Injections. — Antitoxin  should  always  be  given  in  diph- 
theria no  matter  how  late  in  the  disease  the  case  may  first  be  seen. 
In  one  case  first  seen  by  me  on  the  sixth  day,  11,000  units  were 
given  in  three  injections  at  eight-hour  intervals.  The  child  recov- 
ered. In  another  case,  already  referred  to — the  one  of  laryngeal 
diphtheria  in  a  boy  five  years  of  age,  who  was  first  seen  on  the  fifth 
day — 11,000  units  were  given  in  nine  hours  with  prompt  recovery. 
I  have  used  the  antitoxin  as  late  as  the  eighth  day  of  the  disease 


DIPHTHERIA  307 

with  benefit  and  recovery,  and  it  is  my  belief  that  the  patient 
would  not  have  recovered  without  it.  In  order  to  be  signally 
effective,  the  serum  should  be  given  not  later  than  the  third  day. 
The  later  it  is  given,  the  greater  the  amount  required,  and  the  greater 
the  need  of  repeating  the  injection.  Considerable  discredit  has  been 
thrown  upon  the  antitoxin  treatment  by  the  timid  and  by  those  not 
familiar  with  its  use.  We  frequently  hear  of  cases  of  diphtheria 
dying  after  the  administration  of  antitoxin,  the  patient  having  re- 
ceived but  2000  or  3000  units,  and  that  amount  perhaps  late  in  the 
disease.  It  would  be  as  irrational  to  claim  that  quinin  is  of  no 
value  in  malaria,  because  three  or  four  grains  daily  make  no  im- 
pression on  the  disease,  as  it  is  to  claim  that  antitoxin  is  of  no  value 
in  diphtheria,  because  two  or  three  thousand  units  are  given  with- 
out beneficial  results,  even  when  administered  early  in  the  disease. 

Blood  Changes  Due  to  Antitoxin. — It  has  been  claimed  that 
antitoxin  produces  deleterious  changes  in  the  blood,  affecting  par- 
ticularly the  red  blood-corpuscles.  Bearing  on  this  statement  we 
quote  from  Ewing's  "Pathology  of  the  Blood":  "The  red  cells 
in  the  blood  show  no  distinct  or  uniform  effects  from  the  use  of 
antitoxin,  although  in  some  subjects  there  is  a  moderate  reduction 
lasting  a  few  hours.  On  the  other  hand,  the  use  of  antitoxin,  by 
limiting  the  progress  of  the  infection,  tends  to  prevent  further 
disintegration  of  the  blood-cells.  Within  one-half  hour  after  the  in- 
jection of  antitoxin  the  leukocytes,  particularly  the  polynuclear 
form,  if  previously  abundant,  show  a  marked  dissemination,  and 
in  most  cases,  although  the  leukocytosis  returns  after  twenty- 
four  hours,  it  seldom  reaches  its  previous  grade."  Ewing  noted  a 
reduction  of  leukocytes  after  antitoxin  in  all  but  two  fatal  cases, 
while  Schlesinger  found  it  in  all  of  his  examinations.  A  marked 
leukocytosis  is  usually  present  in  diphtheria,  various  writers  estimat- 
ing the  number  in  a  cubic  millimeter  at  from  25,000  in  an  average 
case,  to  50,000  in  a  severe  one. 

Urticaria. — In  20  percent  of  my  cases  urticaria  followed  the  use 
of  antitoxin.  The  most  severe  urticaria  occurring  under  my  ob- 
servation followed  an  injection  of  3000  units.  The  earliest  ap- 
pearance of  the  eruption  was  on  the  fifth  day  following  the  injection  ; 
its  latest  appearance,  on  the  twenty-first  day.  The  urticaria  ap- 
parently differs  in  no  respect  from  that  due  to  other  causes  and  the 
treatment  should  be  the  same.  Among  local  applications,  a  i 
percent  solution  of  carboHc  acid,  or  a  lead  and  opium  wash,  relieves 
the  itching  better  than  docs  any  other  measure.  For  internal  ad- 
ministration, salicylate  of  soda  answers  better  than  any  other  form 
of  medication.  For  a  child  five  years  old  three  grains  well  diluted 
may  be  given  every  two  hours  until  five  doses  have  been  taken  daily, 
the  treatment  being  thus  repeated  every  day  until  the  rash  disappears. 

When  a  member  of  a  family  becomes  ill  with  diphtheria  the  sug- 


3o8  .  CONTAGIOUS   DISEASES 

gestions  in  Quarantines  (page  300)  should  be  carefully  followed 
out. 

Immunization. — In  every  case  of  diphtheria  other  children  of  the 
family  should  be  immunized.  Never  less  than  1000  units  should 
be  given  for  this  purpose,  regardless  of  the  age  of  the  child.  Cul- 
tures should  be  taken  from  the  throats  of  children  and  adults  alike. 
If  the  Klebs-Loeffler  bacillus  is  found,  the  case  must  be  isolated 
and  treated  as  diphtheria,  so  far  as  quarantine  is  concerned.  Two 
of  my  cases  developed  diphtheria  after  immunizing  doses  of  anti- 
toxin. A  child  nine  months  of  age  was  given  3000  units  and  de- 
veloped diphtheria  four  days  afterward.  The  patient  recovered 
after  a  second  injection  of  3000  units.  A  boy  four  years  of  age 
was  given  1000  units  for  immunization.  He  developed  diphtheria 
in  thirty-six  hours,  which  was  controlled  by  the  injection  of  3000 
units.  The  throat  was  clear  in  forty-eight  hours  after  the  second 
injection. 

Choice  of  Antitoxin. — The  author  has  used  successfully  the 
antitoxin  prepared  by  Parke,  Davis  &  Co.,  by  H.  K.  Mulford  & 
Company,  and  by  the  Health  Department,  New  York  city. 


-^^ 


Fig.  29.— "  Record  "  Antitoxin  Syringe. 

Means  of  Injection. — There  are  several  antitoxin  syringes  on 
the  market,  any  one  of  which  may  be  used  if  it  will  admit  of  re- 
peated boiling,  for  in  every  instance  the  syringe  should  be  boiled 
before  using.  The  "Record"  antitoxin  syringe^  (I'ig-  29)  satisfac- 
torily fulfils  these  requirements.  Some  of  the  private  producers  of 
antitoxin  furnish  it  in  glass  bulbs  with  appliances  for  injecting  it 
subcutaneously.  The  advantage  possessed  by  this  combination  is 
its  convenience  and  its  safety,  for  as  the  instrument  has  to  be  used 
but  once,  the  danger  of  infection  by  means  of  a  syringe  which  is 
used  repeatedly  is  thus  avoided. 

Site  for  Injection. — The  skin  over  the  abdomen  between  the  um- 
bilicus and  the  anterior  spine  of  the  ilium  is  doubtless  the  most 
convenient  site  for  the  injection.  The  skin  is  very  loosely  attached 
at  this  point  and  the  serum  passes  freely  under  it,  requiring  very 
little  force  and  producing  no  laceration  of  the  tissues,  nor  does  the 
soreness  of  the  parts  interfere  with  the  child's  customary  position 
in  bed.     If    the    buttocks,    favorite    sites    for    the    injection    with 

'The  "  Record"  antitoxin  syringe  may  be  obtained  of  James  C.  Dougherty, 
409  West  59th  St.,  New  York. 


DIPHTHERIA 


309 


many,  are  selected,  the  needle  should  be  inserted  well  up  on  the 
side,  so  as  not  to  interfere  with  the  child's  resting  on  his  back. 

Before  injecting,  the  skin  should  be  thoroughly  scrubbed  with 
green  soap  and  washed  with  alcohol.  Upon  the  withdrawal  of  the 
needle,  the  skin  should  again  be  washed  with  alcohol  and  a  piece  of 
Z,  O.  plaster,  one  inch  square,  appUed  over  the  site  of  the  injection. 
With  these  precautions  regarding  cleanUness  there  has  never  been,  in 
my  experience,  a  suggestion  of  a  local  infection. 

Remedial  Measures  Other  Than  Antitoxin. — Among  the  many 
remedies  which  have  been  advocated  and  used  from  time  to  time  in 
the  treatment  of  diphtheria,  practically  none  remains  in  use  at  the 
present  time.  During  the  pre-antitoxin  period  I  had  abundant 
opportunity,  in  103  cases  at  the  New  York  Infant  Asylum,  to 
test  the  value  of  drugs,  inhalations,  vaporizing  treatment,  local 
applications,  gargles,  and  sprays.  In  an  article  relating  to  this  epi- 
demic of  diphtheria  which  was  written  by  me  several  years  ago, 
is  the  following  statement:  "The  death-rate  in  the  institution 
from  diphtheria  was  large.  About  60  percent  mortality.  In  so  far 
as  the  methods  of  treatment  were  concerned  all  were  equally  value- 
less. The  mild  and  some  moderately  severe  cases  recovered  under 
good  general  management.  The  severe  cases  died  regardless  of  treat- 
ment." In  other  words,  there  was  no  method  or  scheme  of  treatment 
used  at  that  time  that  was  of  any  signal  value.  Happily,  at  the  pres- 
ent time,  all  the  old  methods  are  forgotten.  We  do  not  need  them. 
Antitoxin  is  a  specific.  The  use  of  sprays  and  gargles  and  applica- 
tions are  of  value  as  a  means  of  cleanliness  only.  For  this  purpose 
the  throat  irrigation  (page  245)  answers  better  than  any  other.  For- 
cible irrigation  of  the  nose  should  not  be  employed.  In  such  cases 
the  danger  of  forcing  infected  material  into  the  eustachian  tube  with 
resulting  secondary  otitis  is  a  real  one.  In  small  children,  if  the 
breathing  is  interfered  with  because  of  membrane  or  tenacious 
secretions  in  the  nose,  a  few  drops  of  liquid  albolene  instilled  every 
hour  will  give  as  much  relief  as  can  be  furnished  by  any  other  local 
measure. 

Sick-room  Regime. — In  the  management  of  diphtheria  the  same 
sick-room  regime  should  be  followed  out  as  in  other  serious  diseases. 
The  temperature  of  the  room  should  never  be  above  70°  F.  and  at  all 
seasons  of  the  vear  there  should  always  be  a  free  communication  with 
the  outer  air  by  means  of  an  open  window.  The  child  should  wear 
its  ordinary  night-clothes  and  the  bed-clothes  should  be  of  the  same 
weight  as  those  used  in  health.  The  nutrition  of  the  patient  is  most 
important.  As  a  rule,  food  is  poorly  taken  because  of  the  pain 
caused  by  swallowing.  Inasmuch  as  but  a  few  ounces  may  be  taken 
at  one  time,  it  is  well  to  give  the  nourishment  in  as  concentrated  a 
form  as  possible.  Milk  should  be  given  as  the  chief  article  of  diet, 
with  the  addition  of  lime-water  or  bicarbonate  of  soda.     If  the  taste 


3IO  CONTAGIOUS   DISEASES 

of  milk  is  disagreeable  to  the  patient,  it  may  be  mixed  with  equal 
parts  of  a  thick  gruel  and  well  salted.  Animal  broths  possess  so 
little  nutriment  that  it  is  unwise  to  use  them.  The  milk,  plain  or 
diluted,  will  often  best  be  taken  if  given  cold  or  cool,  even  by  children 
under  one  year  of  age.  It  will  usually  also  be  taken  from  a  spoon 
or  cup  better  than  from  a  bottle,  because  of  the  discomfort  produced 
bv  drawing  on  the  nipple.  When  sufficient  nourishment  will  not  be 
swallowed,  gavage  (page  134)  may  be  brought  into  use,  or  rectal 
alimentation  (page  139)  may  aid  us  temporarily  in  maintaining  nu- 
trition. The  temperature  is  rarely  high  enough  in  diphtheria  to 
require  the  use  of  any  means  for  its  reduction.  In  case  of  high 
fever  the  sponge-bath  (page  480)  or  cool  pack  (page  481)  will  answer 
the  requirements.  When  the  heart  action  becomes  weak,  irregular,  or 
intermittent,  stimulation  will  be  necessary.  For  this  purpose  three 
drugs  are  of  signal  value — strychnin,  tincture  of  strophanthus,  and 
alcohol. 

Intubation 
To  the  genius  of  the  late  Dr.  Joseph  O'Dwyer,  of  New  York,  is 
due  the  credit  of  perfecting  this  operation,  which  will  forever  stand 
as  a  monument  to  the  inestimable  service  which  he  rendered  to  man- 
kind.    The  O'Dwyer  intubation  set  (Fig.  32)  furnishes  us  with  the 


Fig.  30.— Extubator. 

necessary  instruments  for  the  operation.  Various  modifications  of 
the  tubes,  the  introductor,  and  the  retractor  have  been  attempted 
from  time  to  time  by  others,  but  the  original  perfected  design  of 
O'Dwyer  has  yet  to  be  improved  upon. 

Intubation  of  the  larynx  may  be  required  in  a  retropharyngeal 
abscess,  situated  low  on  the  posterior  pharyngeal  wall.  It  may  be 
required  in  edema  of  the  larynx  and  in  acute  laryngitis.  Its  greatest 
usefulness,  however — that  for  which  it  was  designed — is  to  relieve 
the  stenosis  of  laryngeal  diphtheria.  Before  attempting  to  introduce 
a  tube  into  the  larynx  of  the  living  subject  the  physician  should 


INTUBATION 


311 


familiarize  himself  with  the  operation  on  the  cadaver.  In  no  other 
way  can  the  operation  safely  be  learned.  Attempts  at  intubation 
by  the  unskilled  on  the  living  subject  can  result  only  in  laceration 
and  other  gross  injuries  to  the  parts. 

When  to  intubate  is  a  question  puzzling  alike  to  students  and  to 


Fig.  32.— O'Dwyer  Intubation  Set. 


many  physicians.  It  has  been  variously  answered,  and  many  at- 
tempts have  been  made  to  formulate  a  series  of  cUnical  manifesta- 
tions the  presence  of  which  would  render  the  operation  necessary. 
Thus,  it  has  been  said  that  it  is  indicated  when  there  is  a  pronounced 
recession  of  the  suprasternal  and  infrasternal  regions,  and  when,  as  a 
result  of  stenosis,  air  enters  the  bases  of  the  lungs  but  feebly  or  not 


312 


CONTAGIOUS   DISEASES 


at  all.  It  may  safely  be  said  that  intubation  is  never  done  too  early, 
but  it  is  very  apt  to  be  done  too  late — not  too  late  in  a  great  majority 
of  instances  to  be  of  some  service  to  the  patient,  but  too  late  to  be  of 
the  greatest  possible  service.  My  rule  regarding  intubation  in  laryn- 
geal diphtheria  is  to  intubate  when  I  see  that  the  child  is  becoming 
exhausted  by  his  frantic  struggle  for  breath.  Diphtheria  is  a  disease 
in  which  every  possible  strength-unit  must  be  preserved.     Energy 


Fig.  -?:(.— Position  for  Inttbation. 


wasted  in  supplying  air  is  an  unnecessary  waste,  since  O'Dwyer  has 
shown  us  how  to  introduce  a  tube  into  the  larynx. 

Operation. — For  the  operation  of  intubation,  the  patient  should 
be  wrapped  from  his  shoulders  to  his  feet  in  a  sheet  securely  pinned 
from  top  to  bottom.  The  older  and  stronger  the  child,  the  more  this 
is  necessary  (Fig.  33).  The  patient  is  held  on  the  lap  of  the  nurse, 
who  passes  her  right  hand  around  the  child's  body.  The  child's 
head  rests  on  the  nurse's  right  shoulder,  firmly  held  in  position  by 
her  left  hand.     In  large,  strong  children  it  may  be  necessary  for  a 


INTUBATION  313 

third  person  to  hold  the  child's  head.  The  gag  being  introduced, 
the  operator,  with  instruments  and  hands  disinfected,  holds  the  in- 
troductor  in  his  right  hand,  locates  the  glottis  with  the  forefinger  of 
the  left,  and,  using  it  as  a  guide,  directs  the  tip  of  the  tube  into  the 
larvnx.  He  must  be  certain  that  the  tip  is  properly  placed  before 
exerting  pressure  to  put  the  tube  into  position.  This  can  readily  be 
appreciated  by  one  who  has  practised  on  the  cadaver.  When  posi- 
tive that  the  tip  of  the  tube  is  engaged  in  the  glottis,  gentle  pressure 
will  put  it  into  position.  Force  should  never  be  used,  even  when  the 
tube  is  started  right,  for  the  child  may  require  a  smaller  tube  than  his 
age  indicates.  This  is  rather  unusual,  however,  as  are  the  cases 
which  require  larger  tubes  than  the  age  calls  for.  When  the  tube  is 
easily  coughed  up,  it  is  my  custom  to  introduce  the  next  larger  size. 
With  the  tube  in  position,  the  obturator  is  quickly  removed.  I 
never  trust  to  pressure  on  the  shank  of  the  introductor  to  disengage 
the  obturator,  but  keep  the  guiding  index-finger  of  the  left  hand  on 
the  expanded  head  of  the  tube  in  order  to  insure  its  remaining  in 
position  during  the  extraction  of  the  obturator. 

Results  of  Intubation. — After  the  operation  the  child  who  has 
previously  been  struggling  will  take  a  deep  inspiration  and  cough. 
One  of  the  most  welcome  sounds  to  the  operator  is  the  sharp  rattle 
produced  by  the  passage  of  air  through  the  mucus  which  has  been 
forced  into  the  tube.  This  tells  him  that  the  tube  is  in  position  and 
that  speedy  relief  of  the  stenosis  may  be  expected.  The  intubated 
child  will  usually  cough  vigorously  for  several  minutes,  and  in  so 
doing  may  bring  up  a  quantity  of  mucus  and  shreds  of  membrane. 
I  have  often  been  astonished  at  the  large  pieces  of  membrane  and 
the  quantity  of  thick  mucus  that  can  pass  through  the  compara- 
tively small  lumen  of  the  tube.  In  a  few  cases,  the  presence  of  the 
tube  in  the  larynx  has  caused  such  a  persistent  cough  that  a  seda- 
tive was  required  to  control  it.  Small  doses  of  bromid  of  soda — 
four  grains  every  half  hour  for  two  or  three  hours,  for  a  child  four 
years  of  age — usually  answer  the  purpose.  The  thread,  looped  and 
knotted,  which  has  been  attached  to  the  tube,  should  be  long  enough 
to  extend  four  or  five  inches  beyond  the  lips.  In  case  relief  to  the 
stenosis  is  not  immediately  perceptible  after  the  operation,  or  if  the 
breathing  is  made  more  difficult,  one  may  be  sure  either  that  the 
tube  is  not  in  position  or,  if  in  position,  that  it  is  plugged  with 
membrane,  or  that  membrane  may  have  become  disengaged  and  is 
pushed  downward  ahead  of  the  tube.  A  tube  in  the  esophagus, 
where,  in  my  hospital  service,  I  have  seen  it  placed  by  internes,  may 
exert  sufficient  pressure  upon  the  posterior  portion  of  the  larynx 
effectually  to  impede  respiration. 

Illustrative  Cases. — Several  years  ago  I  was  called  to  intubate  a 
boy  two  years  of  age  who  was  suffering  from  moderate  stenosis  due 
to  diphtheria.     The  tube  was  easily  introduced,  but  its  introduc-_ 


314  CONTAGIOUS   DISEASES 

tion  was  followed  by  entire  cessation  of  respiration.  The  tube 
was  immediately  extracted  by  means  of  the  attached  thread  and  was 
found  to  be  plugged  with  membrane  requiring  considerable  pressure 
with  a  wooden  toothpick  to  dislodge  it.  The  stenosis  was  somewhat 
relieved  as  the  result  of  dilating  the  parts  and  a  removal  of  a  por- 
tion of  the  membrane,  but  not  sufficiently  to  furnish  permanent 
relief  to  the  patient.  The  tube  was  again  introduced,  followed  by  a 
complete  relief  of  the  stenosis. 

When  membrane  is  dislodged  and  pushed  ahead  of  the  tube  it  will 
usually  be  expelled  by  coughing,  after  the  extraction  of  the  tube. 
A  case  of  this  nature,  following  the  withdrawal  of  the  obturator, 
occurred  in  a  child  six  years  of  age,  whose  breathing,  before  difficult, 
was  impossible.  The  child  struggled  violently,  became  much  ex- 
cited, and  with  one  hand  free,  knocked  the  gag  from  his  mouth.  In 
my  efforts  to  extract  the  tube  the  string  broke,  and  while  reintro- 
ducing the  gag  in  order  to  use  the  extractor,  the  child's  struggles  and 
attempts  at  coughing  dislodged  both  the  tube  and  a  large  amount  of 
membrane,  one  piece  of  which,  enclosing  the  tube,  came  out  as  a  per- 
fect cast  of  the  larynx  and  upper  trachea.  The  relief  was  immediate. 
Re-intubation  was  not  attempted  nor  was  it  necessary  later.  The 
child  had  been  given  5000  units  of  antitoxin  twenty-four  hours  before, 
which  helps  explain  the  dislodgment  of  the  membrane. 

With  the  introduction  of  antitoxin,  the  necessity  for  intubation  has 
become  less  frequent.  The  free  use  of  antitoxin — 5000  to  10,000 
units  as  an  initial  dose,  given  with  the  first  sign  of  obstruction  and 
repeated  at  eight-hour  intervals  until  two,  three,  or  more  doses  are 
given — will  further  reduce  the  number  of  cases  requiring  intubation, 
making  it  a  still  rarer  necessity.  Fortunately,  in  laryngeal  obstruc- 
tion due  to  diphtheria,  the  stenosis  is  usually  of  gradually  increasing 
severity,  so  that  by  the  early  use  of  antitoxin  many  cases  are  relieved 
before  the  necessity  for  operation  arises. 

SCARLET  FEVER 
Scarlet  fever  is  one  of  the  most  dangerous  diseases  to  which 
children  are  subject,  because  of  its  marked  tendency  to  complications. 
We  never  know  in  a  given  case,  whether  mild  or  severe,  what  the 
morrow  may  bring  forth.  For  this  reason  the  most  scrupulous  care 
is  absolutely  necessary  in  the  dietetic  and  sick-room  management. 
The  patient  must  be  kept  in  bed  throughout  the  entire  illness,  of 
from  four  to  six  weeks;  i.  e.,  from  the  onset,  first  manifested  by  sore 
throat  and  fever,  until  the  desquamation  is  completed  (see  Quar- 
antine, page  300).  We  must  realize  at  the  outset  the  possibiHties  as 
to  the  virulence  of  the  infection  and  the  complications.  The_^death-_ 
rate  in  scarlet  fever  epidemics  varies  from  10  to  30  percent.  In 
greater  New  York  from  350  to  450  children  under  ten  yearsbf  age 
die  from  scarlet  fever  or  its  complications  every  year.     In  order  to 


SCARLET  FEVER  315 

do  our  full  duty  to  the  patient,  we  must  place  him  in  the  best  pos- 
sible position  for  successfully  combating  the  disease. 

The  Sick-room. — The  sick-room  should  be  as  large  as  it  is  possi- 
ble for  the  family  to  supply.  It  is  desirable  that  it  be  well  lighted 
by  two  windows  which  will  make  free  ventilation  possible.  For  the 
latter  purpose,  the  window-board  (page  43)  answers  well.  There 
should  always  be  a  direct  communication  with  the  open  air,  except 
when  the  child  is  being  bathed  or  its  clothing  changed.  Light  and 
the  free  circulation  of  fresh  air  are  absolutely  necessary  for  the 
proper  management  of  a  severe  case  of  scarlet  fever.  If  possible, 
two  rooms  should  be  used — ^one  for  the  day,  the  other  for  the  night. 
The  room  which  is  not  occupied  should  have  the  window  or  windows 
wide  open.  When  nephritis,  endocarditis,  or  otitis  develops,  it  is  the 
result  of  the  scarlet  fever  poison  or  associated  infection,  and  not  be- 
cause a  window  was  left  open,  or  a  few  rays  of  sunlight  streamed  into 
the  room. 

Clothing. — The  child  requires  no  extra  jacket  or  wraps.  The 
customary  night-gown  with  the  light  gauze  undershirt  and  the  usual 
bed-covering  is  all  that  is  required. 

Urine  Examinations. — The  urine  should  be  examined  for  albumin 
every  day.  It  is  my  practice  to  have  the  family  get  a  few  test-tubes 
and  a  bottle  of  chemically  pure  nitric  acid.  When  the  busy  physician 
has  the  daily  specimen  sent  to  his  ofhce  or  carries  it  home  himself, 
it  is  sometimes  forgotten,  misplaced,  or  lost.  During  convalescence, 
when  the  daily  visit  is  not  made,  the  nurse  or  some  intelligent  mem- 
ber of  the  family  can  be  instructed  to  make  the  test  and  report  if 
trouble  is  discovered.  Because  of  a  lack  of  these  precautions, 
nephritis  may  easily  be  overlooked  until  puffiness  about  the  eves  and 
edema  of  the  lower  extremities  are  discovered  by  the  attendant  after 
albumin  had  been  present  in  the  urine  for  several  da  vs. 

Diet. — In  the  bottle-fed  the  food  strength  should  be  reduced  one- 
half  during  the  acute  febrile  stage  by  the  use  of  boiled  water.  If  the 
child  is  getting  eight  ounces  of  a  milk  mixture,  four  ounces  of  this  mix- 
ture should  be  given  with  four  ounces  of  water.  In  older  children, 
the  diet  is  not  only  considerably  restricted  during  the  acute  stage, 
but  during  the  entire  course  of  the  disease.  During  the  acute  febrile 
stage  diluted  milk,  gruels,  and  orange-juice  should  constitute  the 
diet.  For  a  child  from  two  to  four  years  of  age,  five  ounces  of  milk 
with  five  ounces  of  barley  gruel  No.  2  (see  formulary,  page  124)  may 
be  given  at  four-hour  intervals — four  to  five  feedings  in  twenty-four 
hours,  which  make  an  acceptable  diet.  Variations  may  be  made  in 
the  gruels  used.  Wheat,  rice,  and  granum  may  all  be  brought  into 
use,  made  as  suggested  in  the  formulary  and  given  with  equal  parts 
of  milk.  It  is  always  well,  in  the  feeding  of  sick  chijdren,  to  provide 
for  some  variety  in  the  food,  in  order  that  the  child  may  not  tire  of  it. 
The  juice  of  one-half  an  orange  may  be  given  twice  daily,  three  hours 


3l6  CONTAGIOUS   DISEASES 

after  the  milk  and  gruel  feeding.  For  the  sake  of  variety  in  the  diet,  I 
occasionally  allow  a  glass  of  whey  or  kumyss,  or  a  glass  of  skimmed 
milk  containing  one-half  ounce  of  lime-water.  Toasted  bread,  zwie- 
back, or  plain  crackers,  dry  or  in  diluted  milk,  may  be  given  occa- 
sionally. 

The  exclusive  milk  diet  in  the  management  of  scarlet  fever,  about 
which  we  have  all  heard  and  still  hear  a  great  deal,  has  not  been  as 
successful  in  my  hands  as  has  the  foregoing.  My  observation  has 
been  that  the  exclusive  milk  diet  is  apt  to  produce  constipation, 
intestinal  indigestion,  coated  tongue,  loss  of  appetite — in  fact,  the 
child  "grows  stale"  on  the  milk,  which  is  to  be  our  dietetic  mainstay 
during  the  weeks  that  are  to  follow.  During  the  post-febrile  period, 
slight  additions  are  made  to  the  diet  by  the  use  of  farina,  hominy, 
wheatena,  and  the  lighter  cereals,  prepared  as  a  porridge  with  a 
sprinkUng  of  sugar  and  a  httle  milk.  The  child's  customary  diet 
should  not  be  resumed  until  four  weeks  have  elapsed  from  the  com- 
mencement of  the  attack.  If  the  case  has  been  a  severe  one,  showing 
marked  svstemic  infection,  six  weeks  should  elapse  before  the  full 
diet  is  resumed. 

Bowel  Evacuation. — There  should  be  one  evacuation  of  the  bowels 
daily.  If  this  does  not  take  place,  a  soap-water  enema  should  be 
given.  If,  on  account  of  the  diet  and  the  recumbent  position,  there 
is  a  tendency  to  constipation,  a  glass  of  malted  milk — six  teaspoon- 
fuls  of  the  malted  milk  to  eight  ounces  of  water — as  a  part  of  the 
evening  meal  will  be  of  service  in  relieving  the  condition.  The  ad- 
dition of  one  teaspoonful  of  cocoa  will  be  grateful  where  the  taste  of 
malted  milk  is  objectionable. 

Laxatives. — As  a  laxative  during  the  acute  febrile  stage,  citrate 
of  magnesia  is  very  satisfactory.  As  a  rule,  children  like  it.  It  may 
be  given  in  doses  of  from  two  to  four  ounces,  to  children  from  two  to 
five  years  of  age.  In  case  it  is  not  well  taken,  from  one  to  two  tea- 
spoonfuls  of  the  aromatic  cascara  may  be  given. 

Specific  Medication. — There  is  no  specific  medical  treatment  for 
scarlet  fever.  Many  of  my  cases  have  passed  through  the  entire  ill- 
ness without  the  use  of  any  other  measures  than  those  suggested 
above. 

Serum  Treatment. — The  value  of  the  serum  treatment  has  been 
by  no  means  demonstrated,  and  its  use  is  not  advised.  The  pre- 
paration of  serum  and  its  use  before  we  know  the  nature  of  the  scarlet 
fever  poison  is,  to  say  the  least,  premature.  The  only  use  of  serum 
therapy,  so  far  as  we  know  at  the  present  time,  regardless  of  the  kind 
employed,  is  to  assist  the  organism  in  battling  with  the  disease. 

Nursing. — As  the  course  of  scarlet  fever  is  distinctly  cyclic  in 
character,  much  can  be  done  in  the  most  severe  cases  to  prevent 
complications,  and  to  relieve  the  patient  of  his  temporary  burden. 
Since  one  of  the  most  important  offices  we  have  to  perform  is  to 


SCARLET   FEVER 


317 


keep  the  vital  force  at  the  highest  possible  point,  we  must  do  every- 
thing in  our  power  to  preserve  the  natural  resistance  of  the  patient, 
and  this  we  have  done  in  no  small  degree  when  we  have  so  arranged 
clothing,  diet,  fresh  air,  bowel  evacuation,  sleep,  and  quiet,  as  to 
insure  the  child's  comfort  and  well-being.  The  amount  of  vitahty 
wasted  by  an  uncomfortable,  restless  child  in  twenty-four  hours  may 
turn  the  case  from  a  successful  to  a  fatal  issue. 

I  fully  believe  in  "spoiling"  a  sick  child.  If  a  child  is  more  at 
ease  with  the  mother,  the  mother's  place  is  with  the  child.  If  the 
mother's  presence  disturbs  the  child,  as  it  does  in  some  instances, 
she  should  be  kept  in  the  background.  If  it  is  apparent  that  the  nurse 
selected  is  not  to  the  child's  liking,  or  not  adapted  to  the  case,  another 
should  be  secured.  I  have  been  obHged  repeatedly  to  take  my  best 
nurses  from  children  gravely  ill,  because  the  patients  were  irritable 
and  unhappy  in  their  presence. 

Quiet. — Quiet  is  most  necessary.  One  person  in  the  sick-room 
with  a  child  very  ill  is  all  that  should  be  allowed.  A  second  person  is 
of  no  service,  and  if  admitted,  good  air  is  vitiated;  moreover,  it  is  not 
to  be  expected  that  two  persons  of  the  "female  persuasion"  in  the  same 
room  will  not  talk! 

Indications  of  Severity. — The  physician  who  has  seen  a  few  cases 
of  scarlet  fever  can  usually  judge  within  the  first  three  days  as  to  the 
severity  of  the  infection.  It  is  indicated  by  the  character  of  the  rash, 
the  height  of  the  temperature,  and  to  a  lesser  degree  by  the  severity 
of  the  angina.  A  case  which,  on  the  second  or  third  day  of  the  rash, 
shows  a  temperature  range  from  101°  to  103°  F.  means  that  we  have 
not  a  very  severe  infection  and  that  the  case  probably  will  be  mild. 

Control  of  Fever. — A  case  in  which  the  fever  rises  suddenly  to 
104°  or  105°  F.  with  a  tendency  to  remain  there,  means  that  we 
have  a  severe  infection  to  deal  with.  I  find  it  a  safe  rule  not  to 
allow  the  temperature  to  go  much  above  104°  F.  A  higher  tem- 
perature than  this  necessitates  an  overworked  heart.  For  the  pur- 
pose of  controlUng  the  temperature,  a  fifteen-minute  sponging  every 
hour  with  water  at  90°  F.  may  be  tried. 

Packs. — If  sponging  does  not  answer,  the  pack  (page  481)  should 
be  brought  into  use.  vSimply  because  the  child  has  a  rash  is  no  contra- 
indication to  the  application  of  moderate  cold  to  the  skin.  The  pack 
may  be  used  in  scarlet  fever  just  as  in  pneumonia  or  typhoid  fever. 
The  fear  that  the  disease  may  "strike  in"  and  kill  the  patient  is  one 
of  the  many  inexpHcable  ideas  of  the  laity  with  no  foundation  in 
fact.  The  child  is  placed  in  the  pack  at  95°  F.  It  will  rarely  be 
necessary  to  reduce  the  temperature  of  the  pack  below  80°  F.  If 
the  case  is  of  the  fulminating  type  with  persistent  high  temperature, 
it  may  gradually  be  reduced  to  70°  F.  In  reducing  the  temperature 
of  the  pack,  the  towel  is  not  to  be  removed  from  the  patient.  He  is 
turned  from  side  to  side  and  the  towel  moistened  with  water  at  the 


31' 


CONTAGIOUS   DISEASES 


desired  temperature.  Time  and  again  I  have  seen  children  who 
were  tossing  about  the  bed  deHrious  and  sleepless,  fall  into  a  quiet 
sleep  when  placed  in  a  pack.  With  a  reduction  of  the  temperature, 
there  is  a  corresponding  diminution  in  the  pulse-beats  of  from  twenty 
to  thirty  a  minute.  When  we  think  what  a  saving  this  is  to  the  work 
of  the  heart,  its  benefit  is  most  apparent. 

Tub-baths. — The  full  tub-bath  at  a  temperature  of  95°  F.  for  ten 
minutes  at  the  commencement  of  a  case  in  which  there  is  a  great  deal 
of  restlessness  and  irritability,  will  often  act  most  satisfactorily  in 
quieting  the  patient.  Tub-bathing,  however,  requires  a  great  deal 
of  handling  of  the  patient,  and  in  the  cases  in  which  there  is  a 
persistent  high  temperature,  and  in  those  in  which  it  mounts  up 
suddenly  after  the  bath,  the  pack  is  by  far  the  more  satisfactory. 

Oil  Inunction. — The  itching  and  burning  of  the  skin  in  scarlet 
fever  are  most  distressing.  This  also  is  relieved  to  a  considerable 
degree  by  the  pack.  The  child's  comfort  will  also  be  greatly  en- 
hanced by  an  inunction  twice  daily  of  cold-cream  or  liquid  albolene. 
Vaselin  or  olive  oil  may  be  used,  but  they  are  much  less  satisfac- 
tory.    Vaselin  will  act  as  an  irritant  to  some  sensitive  skins. 

During  the  period  of  desquamation  the  oily  applications  largely 
prevent  a  free  distribution  of  the  scales,  and  thus  Umit  the  chance  of 
infecting  others  through  the  clothing  and  other  objects  in  the  room. 

Heart  Stimulants. — If,  during  sleep,  the  pulse  is  over  150  a  min- 
ute with  a  weakened  first  sound,  a  heart  stimulant  is  necessary.  For 
a  child  one  year  of  age,  one  drop  of  tincture  of  strophanthus  at  two- 
hour  intervals,  or  an  equal  amount  of  the  tincture  of  digitalis,  should 
be  given.  On  account  of  its  being  well  borne  by  the  stomach,  the 
tincture  of  strophanthus  is  always  preferred.  Strychnin  is  a  remedy 
of  considerable  value  as  a  heart  stimulant.  When  the  pulse  is  soft 
and  the  heart  action  shows  a  tendency  to  irregularity,  2^0  grain  may 
be  given  every  two  to  four  hours  to  a  child  from  one  to  three 
years  of  age,  and  yi^  grain  to  a  child  from  three  to  six  years  of  age, 
at  intervals  of  from  two  to  four  hours.  Alcohol  should  be  used  only 
in  the  septic,  asthenic  cases  when  other  means  of  stimulation  have 
failed.  In  such  instances  it  should  be  used  freely.  In  a  few  cases  I 
have  used  it  in  very  large  quantities  with  striking  benefit.  Begin- 
ning with  one-half  dram  of  whisky  every  two  hours,  it  may  be  in- 
creased gradually  until  its  beneficial  effects  are  noticed  on  the  heart 
action.  It  is  astonishing  how  much  alcohol  may  be  given,  in  a  pro- 
foundly septic  case,  without  the  slightest  effect,  except  an  improve- 
ment in  the  heart  action,  and  a  corresponding  improvement  in  the 
child's  general  condition. 

Care  of  Throat  and  Nose. — The  throat  and  nose  demand  our  at- 
tention during  the  acute  stage.  For  the  nose  toilet  in  older  children, 
a  solution  of  menthol  and  hquid  albolene  is  used  by  means  of  an 
atomizer  (Fig.  34)  and  in  the  very  young  by  instillation  with  a 
medicine-dropper.     A  forcible  syringing  of  the  nose  in  a  young  child 


SCARLET  FEVER 


319 


is  not  a  safe  procedure  even  in  the  most  skilled  hands.  Local  treat- 
ment of  the  throat  depends  entirely  upon  its  condition.  If  the 
mucous  membrane  is  swollen,  edematous,  and  covered  with  a  glairy 
mucopurulent  secretion,  or  if  there  is  a  pseudo-membrane,  or  if  there 
is  much  pain  or  discomfort  upon  swallowing,  local  treatment  is  re- 
quired. The  child  is  made  to  gargle,  if  old  enough,  or,  what  is  far 
better,  the  throat  is  irrigated  with  hot  saline  solution,  at  120°  F. 
This  is  done  as  is  described  on  page  238.  Force  will  be  required 
in  the  very  young.  In  older  children,  the  relief  from  pain  that  is 
experienced  by  free  irrigation  is  so  great  that  usually  the  child  takes 
the  tube  in  its  mouth  gladly  for  the  future  irrigations.  The  use  of 
antiseptic  gargles  and  washes  has  not  seemed  to  me  to  possess  any 


Fig.  34.— The  de  Vilbiss  Oil  Atomizer. 

value  other  than  that  of  cleanliness,  and  free  douching  accomphshes 
this  in  a  far  more  satisfactory  manner. 

Complications. — Cervical  Adenitis. — Cervical  adenitis  is  a  very 
frequent  complication  of  scarlet  fever.  With  the  first  sign  of  a 
swollen  gland,  apply  an  ice-bag  and  keep  it  constantly  apphed  day 
and  night.  If  this  is  not  possible,  apply  30  percent  ichthyol  in  zinc 
ointment,  which  is  kept  bound  on  the  parts,  the  appUcation  being 
renewed  every  three  hours.  Cataplasma  kaolini  may  also  be  used. 
It  is  spread  on  a  piece  of  linen  and  applied  over  the  swollen  area.  It 
should  be  renewed  at  six-hour  intervals.  Whether  the  ice-bag,  the 
ichthyol,  or  the  emplastrum  kaolini  is  used,  Crede's  ointment  may  be 
given  a  trial,  ten  grains  being  rubbed  into  the  skin  over  the  swollen 
gland  for  fifteen  minutes  twice  daily. 

Otitis. — Otitis  is  a  comphcation  in  from  10  to  30  percent  of  the 
cases  of  scarlet  fever.     In  view  of  the  grave  possibilities  of  mastoid 


320  CONTAGIOUS    DISEASES 

involvement,  sinus  thrombosis,  and  jugular  bulb  infection,  the  pres- 
ence of  pus  in  the  middle  ear  should  be  promptly  detected,  and  the 
pus  evacuated  by  a  free  incision  of  the  drum  membrane.  The  pres- 
ence of  middle-ear  infection  may  be  suggested  by  a  pain  or  a  sensa- 
tion of  fullness  in  those  old  enough  to  locate  it.  In  infants,  restless- 
ness, sleeplessness,  or  tenderness  on  manipulation  in  cleansing  the 
ears  may  be  the  only  objective  signs  of  the  trouble.  In  the  majority 
of  my  cases  of  otitis,  none  of  the  above  signs  of  pain  and  discomfort 
were  present.  The  ear  involvement  was  suggested  because  of  a  contin- 
ued elevation  of  temperature  which  could  not  otherwise  be  accounted 
for.  With  a  persistent  elevation  of  the  temperature  of  unknown 
origin  following  scarlet  fever,  the  ears  should  be  examined  by  an  ex- 
pert in  otoscopy.  As  a  routine  measure  during  the  fever,  the  condi- 
tion of  the  drum  membrane  should  be  noted  at  least  every  second  day. 

As  stated  above,  otitis  develops  in  from  lo  to  30  percent  of  the 
cases,  depending  somewhat  upon  the  character  of  the  epidemic,  but 
more  upon  the  age  of  the  patient.  The  younger  the  child,  the 
greater  the  danger  of  ear  involvement.  Many  cases  of  deafness 
which  we  meet  had  their  origin  in  an  attack  of  scarlet  fever,  and  are 
due  to  somebody's  ignorance  or  neglect.  Among  185  cases  of  scarlat- 
inal otitis,  reported  by  Bezold  and  quoted  by  Holt,  in  30  there  was 
entire  destruction  of  the  membrana  tympani;  in  59,  the  perforation 
comprised  two-thirds  or  more  of  the  membrane;  in  13,  there  were 
small  perforations;  in  44,  there  were  granulations  or  polypi;  in  15, 
there  was  total  loss  of  hearing  on  one  side,  and  in  6  of  the  cases  upon 
both  sides;  in  77,  the  hearing  distance  for  low  voice  was  less  than 
twenty  feet.  May,  of  New  York,  has  collected  statistics  of  5613 
deaf-mutes,  of  whom  572  owed  their  condition  to  otitis  following 
scarlet  fever.  When  we  consider  how  many  cases  of  permanent  ear 
defects  have  occurred  and  do  occur  every  year  as  a  result  of  careless- 
ness or  lack  of  even  an  elementary  knowledge  of  aural  diagnosis,  we 
do  not  feel  inclined  to  congratulate  the  members  of  the  medical  pro- 
fession as  to  their  ability  to  complete  their  cases.  The  bacteriology 
of  scarlatinal  otitis  is  the  same  as  in  suppurative  otitis  developing 
with  or  following  any  other  infectious  disease,  except  that  there  is  a 
greater  tendency  to  severity  because  of  the  liability  to  streptococcus 
infection.  Prompt  relief  demands  prompt  recognition  of  the  con- 
dition of  the  drum  membrane,  with  evacuation  of  the  pus  and  suitable 
after-treatment.  (See  Acute  Suppurative  Otitis,  page  420.)  This 
will  not  be  possible  if  the  practitioner  does  not  examine  the  ears  or  is 
not  sufficiently  expert  to  recognize  a  diseased  condition  when  he  sees  it. 

Cardiac  Involvement. — Heart  complications  are  not  particularly 
frequent  in  scarlet  fever.  Nevertheless  the  heart  should  be  examined 
daily.  In  my  own  observations,  they  have  been  present  in  about  2  per- 
cent of  the  cases.  The  treatment  is  laid  down  elsewhere  under  appro- 
priate headings. 


WHOOPING-COUGH — PERTUSSIS  32  I 

Nephritis. — Early  in  the  cases  of  severe  infection  there  will  often  be 
discovered  a  transient  albuminuria  with  a  few  hyaline  casts.  There 
may  be  slight  suppression  of  the  urine.  In  but  one  of  my  cases  was 
there  complete  anuria  at  this  stage  of  the  disease.  Within  thirty-six 
hours  after  the  first  sign  of  the  disease,  the  kidneys  ceased  to  act,  and 
the  child  died  on  the  third  day,  from  the  acute  diffuse  nephritis.  The 
condition  of  the  kidney  giving  rise  to  albuminuria  is  best  reheved  by 
attention  to  the  skin  function  by  the  use  of  a  bath  at  a  temperature 
of  105°  F.  every  six  or  eight  hours.  The  child  may  remain  in  the 
bath  for  ten  minutes,  during  which  time  the  skin  should  be  vigorously 
rubbed  with  the  bare  hand.  The  tincture  of  aconite  in  doses  of  one 
drop,  with  five  drops  of  sweet  spirits  of  niter  for  a  child  eighteen 
months  of  age,  will  usually  produce  a  satisfactory  skin  action. 

What  is  known  as  scarlatinal  nephritis  rarely  appears  before  the 
third  week  of  the  disease.  I  have  known  cases  to  occur  as  late  as  the 
sixth  week.  The  management  of  this  complication  will  be  found  on 
page  343- 

Arthritis  as  a  complication  of  scarlet  fever  is  seen  in  onlv  a  few  of 
the  cases — about  3  percent.  There  may  be  swelling  or  redness  of  the 
parts,  or  both  these  symptoms  may  be  absent.  Whether  the  swelling 
is  present  or  not,  the  joints  are  very  painful  on  manipulation.  Affected 
joints  should  be  wrapped  in  old  hnen,  saturated  with  a  lead  and 
opium  solution,  and  the  dressing  renewed  every  six  hours.  The  fol- 
lowing lotion  has  answered  well  in  a  few  cases : 

I^.     Mentholis o  ij 

Tincturse  opii 5  iv 

Spirit!  vini  recti q.  s.  ad   5  vj 

Soft  linen  is  moistened  with  the  lotion  and  wrapped  about  the  parts 
and  covered  with  oiled  silk  or  rubber  tissue.  The  part  affected  is  then 
wrapped  in  flannel  or  cotton-wool.  The  lotion  may  be  freshly  applied 
at  intervals  of  from  four  to  six  hours.  The  only  objection  to  its  use 
is  the  odor  of  the  menthol.  Internally,  to  a  child  four  years  of  age, 
aspirin  may  be  given  in  doses  of  five  grains,  with  ten  grains  of  the 
bicarbonate  of  soda  at  four-hour  intervals,  four  doses  being  given  in 
the  twenty-four  hours.  Salicylate  of  soda  may  be  used  in  small 
doses;  but,  as  it  may  be  badly  borne  by  the  stomach,  aspirin  is 
preferable. 

WHOOPING-COUGH— PERTUSSIS 

As  an  infectious  disease  of  importance,  pertussis  may  be  classed 
with  diphtheria  and  scarlet  fever.  It  is  probably  the  cause  of  more 
deaths  todav  than  is  any  other  infectious  disease.  It  does  not  kill 
directly  through  the  means  of  a  specific  poison,  as  do  diphtheria  and 
scarlatina;  but,  on  account  of  its  prolonged  course  and  its  many 
complications,  it  is  equally  effective  as  a  life-destroyer. 

Susceptibility. — That  pertussis  is  one  of  the  most  infectious  of  dis- 


322  CONTAGIOUS   DISEASES 

eases  is  well  illustrated  by  the  following  history :  On  a  bright  cold  day 
in  December  a  patient  of  mine,  nine  months  of  age,  passed  in  its  car- 
riage on  the  street  a  child  of  about  the  same  age  who  had  pertussis. 
This  child  was  also  in  its  carriage.  My  patient  took  the  disease.  There 
was  no  other  possible  source  of  infection.  That  pertussis  may  be 
conveyed  through  the  medium  of  the  clothing  of  a  second  person  is 
exceedingly  doubtful.  Direct  exposure  seems  necessary  for  infection 
to  take  place.  The  period  of  infection  dates  from  the  beginning  of 
the  catarrhal  stage,  and  lasts  for  two  or  three  weeks  from  the  cessa- 
tion of  the  paroxysms.  The  period  of  incubation  is  from  seven  to 
fourteen  days. 

When  pertussis  breaks  out  in  a  school  or  in  an  institution  for 
children,  it  is  practically  impossible  to  prevent  an  epidemic.  This 
is  because  the  disease  is  infectious  during  the  early  catarrhal  stage, 
which  lasts  from  one  to  two  weeks.  During  this  time  the  only  symp- 
tom is  a  cough,  and  perhaps  a  sHght  degree  of  bronchitis,  such  as  we 
meet  in  a  common  cold. 

The  previous  state  of  health  appears  to  exert  no  influence  as  far 
as  the  susceptibility  is  concerned.  The  strong  and  the  delicate  are 
alike  predisposed  to  infection.  The  very  young  and  the  adult  are 
less  liable  to  take  the  disease.  From  the  fourth  month  to  the  third 
year  is  the  most  susceptible  time  of  life.  Cases  have  been  reported 
in  children  one  week  old.  Any  other  concurrent  infectious  disease 
exerts  no  influence  upon  the  course  of  the  pertussis.  It  has  been 
claimed  that  the  advent  of  diphtheria  or  scarlet  fever  during  an 
attack  of  pertussis  shortened  and  modified  the  course  of  the  per- 
tussis. My  experience  does  not  corroborate  this  statement.  Other 
affections,  which  may  develop  during  an  attack,  simply  increase  the 
burden  to  be  borne  by  the  patient.  The  largest  number  of  cases  de- 
velop during  the  warmer  months,  from  May  to  November.  This 
may  be  accounted  for  in  part  by  the  fact  that  at  this  period  of  the  year 
the  infected  child  comes  more  frequently  in  contact  with  its  unpro- 
tected neighbor.  It  tends  to  disprove,  however,  that  catarrhal  affec- 
tions of  the  respiratory  tract  predispose  to  the  disease,  as  respiratory 
affections  in  the  young  during  the  warmer  months  are  notably  rare. 
The  normal  mucous  membrane  of  the  healthy  offers  no  greater  re- 
sistance than  does  the  diseased  structure  of  the  ailing.  We  have,  in 
the  early  stages  of  pertussis,  not  simply  a  bronchitis,  as  has  been 
claimed,  but  a  catarrhal  process  due  to  a  specific  infection. 

Interesting  observations  relative  to  susceptibility  to  measles  and 
pertussis  were  made  by  Biedert.  After  an  absence  of  sixteen  years, 
both  these  diseases  broke  out  in  a  German  village  at  about  the  same 
time.  There  were  401  children  in  the  village  under  fourteen  years 
of  age.  These  children  had  never  been  far  from  home,  and  not  one  of 
them  had  had  either  measles  or  pertussis.     Of  this  number,  344 


WHOOPING-COUGH — PERTUSSIS  323 

came  down  with  measles  and  366  with  pertussis,  340  having  both 
diseases  at  once. 

The  susceptibihty  of  these  unprotected  children  to  pertussis  was, 
therefore,  95.5  percent;  to  measles,  85.8  percent.  The  ages  of  those 
who  escaped  pertussis  were  as  follows:  Seven  were  under  five  years 
of  age ;  four  between  five  and  ten  years ;  nine  between  ten  and  four- 
teen years. 

Complications. — The  complications  of  pertussis  are  many,  and  it 
is  through  them  that  the  disease  is  so  destructive  to  Hfe.  The  mor- 
tahty  of  pertussis  is  generally  estimated  at  from  4  to  6  percent. 
That  it  is  actually  much  higher  than  this  is  well  known  to  every  one 
who  has  seen  much  of  the  disease.  The  most  fatal  complication  is, 
in  winter,  bronchopneumonia,  and,  in  summer,  gastro-enteric  disease. 
Convulsions  are  not  an  infrequent  complication  and  may  be  fatal. 
Malnutrition  often  follows  a  severe  attack  in  the  delicate  bottle-fed 
children,  thus  paving  the  way  for  intercurrent  disease.  Tuberculosis 
not  infrequently  follows  a  prolonged  attack  of  pertussis.  Blindness, 
deafness,  and  motor  disturbances  have  all  been  observed  during  attacks 
of  pertussis,  which  resulted  in  complete  recovery.  These  cases  may 
be  explained  as  follows :  During  a  severe  paroxysm  the  cerebral  cir- 
culation is  greatly  disturbed,  resulting  in  a  moderate  congestion  or 
venous  hyperemia,  which  produces  a  disturbance  of  nutrition  in 
certain  portions  of  the  brain.  With  the  return  to  the  normal,  these 
symptoms  all  disappear. 

Diagnosis. — The  diagnosis  of  pertussis  is  most  dii^cult  in  the 
early  stages,  before  the  whoop  or  the  convulsive  nature  of  the 
paroxysm  develops.  Even  a  spasmodic  cough  does  not  alwavs  mean . 
that  we  have  a  developing  pertussis.  The  cough,  if  more  troublesome 
at  night,  favors  a  diagnosis  of  pertussis.  Further,  if  we  have  a 
pertussis  to  deal  with,  the  cough  grows  steadily  worse,  and  resists  all 
the  usual  methods  of  treatment,  the  whoop  soon  establishing  the 
diagnosis.  In  rachitic  children,  and  in  those  in  whom  the  nerv^ous 
element  is  prominent,  the  cough  of  an  ordinary  cold  is  often  of  a  de- 
cidedly paroxysmal  character,  especially  when  there  is  an  acute  or 
subacute  laryngitis.     The  mild  cases  are  also  difficult  of  diagnosis. 

Illustrative  Cases. — Recently  two  patients,  aged  eight  and  ten 
years  respectively,  went  through  an  attack  of  pertussis  with  but  two 
or  three  severe  paroxysmal  coughing  attacks.  Two  other  cases  seen 
in  private  practice  show  also  how  mild  the  course  may  be :  The  pa- 
tients, brother  and  sister,  aged  six  and  eight  years  respectively, 
commenced  coughing  about  ten  days  after  exposure.  The  cough 
was  paroxysmal,  with  from  three  to  five  seizures  in  twenty-four 
hours.  The  boy  whooped  only  three  times  during  the  entire  course 
of  the  disease;  the  girl  never  whooped  at  all.  Vomiting  never  oc- 
curred with  a  paroxysm.  Both  coughed  six  weeks.  These  children 
had  neither  adenoids  nor  bronchitis. 


324  CONTAGIOUS    DISEASES 

Often  the  very  young  and  the  very  delicate  do  not  whoop  even 
during  a  severe  attack.  Among  the  severe  cases,  convulsions  and 
hemorrhage  from  the  nose,  ears,  and  eyes,  were  seen  from  time  to 
time.  A  very  severe  seizure  in  a  girl  nine  months  old  was  followed 
by  small  extravasations  of  blood  into  the  skin  of  the  entire  body. 

In  all  cases  of  severe  cough  of  uncertain  origin,  the  nasopharyngeal 
vault  must  always  be  examined  for  adenoid  growths.  This,  in 
young  children,  can  properly  be  done  only  by  the  use  of  the  index- 
finger. 

Pertussis  in  children  under  eighteen  months  of  age  must  ever  be 
regarded  in  a  serious  light.  Delicate  and  rachitic  children  should  be 
carefully  guarded  against  the  disease.  Bronchopneumonia  and 
gastro-enteric  troubles  are  the  most  frequent  compHcations  among 
this  class  of  children.  The  majority  of  healthy  children  over  eighteen 
months  of  age  bear  an  attack  without  any  great  inconvenience. 

Treatment. — In  considering  the  management  of  pertussis  we  are 
iirst  to  remember  that  the  disease  is  self -limited,  that  it  cannot  be 
cured  by  treatment,  and  that,  in  common  with  the  other  infectious 
diseases,  all  we  can  do  is  to  make  it  as  easy  as  possible  for  the  pa- 
tient to  bear.  We  cannot  shorten  the  attack,  but  we  can  lessen  the 
number  and  severity  of  the  paroxysms.  This  is  to  be  accomplished 
by  the  use  of  drugs  administered  by  the  mouth.  The  rubbing  of  a 
few  drops  of  Roache's  embrocation  on  the  stomach  is,  of  course, 
valueless.  The  believers  in  the  theory  that  the  chief  seat  of  trouble 
is  in  the  nose,  have  advocated  and  brought  into  use  the  insufflation 
of  various  kinds  of  powders,  prominent  among  which  are  boric  acid, 
resorcin,  and  ground  coffee.  This  treatment,  as  might  be  expected, 
is  of  no  service. 

During  a  three  years'  epidemic  of  whooping-cough  in  the 
Country  Branch  of  the  New  York  Infant  Asylum,  from  sixty  to 
ninety  children  were  constantly  in  quarantine.  New  cases  developed 
about  as  rapidly  as  the  old  ones  were  discharged.  During  the  epi- 
demic children  were  quarantined  who  did  not  have  the  disease.  On 
the  other  hand,  an  early  diagnosis  was  frequently  made  before  the 
onset  of  the  spasmodic  stage,  by  excluding  all  possible  causative  fac- 
tors, such  as  pharyngitis,  larvngitis,  and  bronchitis. 

The  cases  as  they  developed  were  divided  into  groups  of  twenty. 
They  were  allowed  to  cough  untreated  until  the  height  of  the  par- 
oxysmal stage  was  reached.  This  usually  required  from  ten  to  four- 
teen days  from  the  commencement  of  the  cough.  Careful  record 
was  kept  day  and  night  of  the  number  and  severity  of  the  paroxysms. 
When  there  was  no  increase  either  in  number  or  severity  for  three 
days,  we  believed  the  height  of  the  paroxysmal  stage  had  been 
reached,  and  the  drug  selected  was  brought  into  use.  The  ages  of  the 
cases  treated  varied  from  six  weeks  to  twenty-six  years.  Only  three 
patients  had  reached  adult  life.      Five-sixths  of  the  patients  were 


WHOOPING-COUGH — PERTUSSIS  325 

under  four  years  of  age.  One-half  were  under  two  years.  The  dura- 
tion of  the  attacks  ranged  from  three  to  twenty  weeks.  From  six  to 
eight  weeks  was  the  usual  duration.  In  several  the  attacks  were  so 
mild  that  a  diagnosis  was  difficult. 

Drugs. — The  drug  treatment  consisted  in  insufflations,  internal 
administration,  and  inhalations.  The  treatment  in  which  drugs  did 
not  enter  was  in  the  use  of  the  steam  spray  and  fresh  air.  Resorcin 
and  boric  acid  combined  with  bicarbonate  of  soda  were  used  bv  means 
of  insufflations  in  six  test  institution-cases,  and  discontinued  after 
three  days.  The  treatment  was  found  impracticable  and  useless. 
Inhalations  of  vapo-cresolene  were  used  in  ten  other  institution-cases. 
Apparently  it  had  no  effect  whatever  in  modifying  the  disease.  In 
private  practice  vapo-cresolene  has  sometimes  a  decided  sedative 
influence  upon  the  disturbed  nervous  state  of  the  parents  and  does 
not  harm  the  child!  It  has  been  used  with  my  permission  in  many 
private  cases.  Medicated  steam  inhalations,  creosote,  turpentine, 
and  wine  of  ipecac  were  used  in  many  cases  with  decidedly  beneficial 
results.  The  cases  selected  for  the  inhalations  were  those  of  the 
very  young  and  delicate,  with  a  complicating  bronchitis,  the  steam 
being  used  in  connection  with  other  treatment.  The  drugs  selected 
for  internal  administration  were  alum,  fluidextract  of  horse-chestnut 
leaves,  dilute  nitric  acid,  hydrochlorate  of  cocain,  bromoform,  quinin, 
the  bromids,  belladonna,  and  antipyrin. 

The  fluidextract  of  horse-chestnut  leaves  and  dilute  nitric  acid 
were  each  used  in  twenty  test  institution-cases.  After  a  trial  of 
five  days  they  proved  valueless,  or  objectionable  on  account  of  the 
vomiting  produced,  and  were  then  discontinued.  Alum  appeared  to 
be  of  some  service,  but  it  was  badly  borne  by  the  stomach.  Bromo- 
form was  used  in  sixteen  dispensary  and  in  six  private  patients.  In 
three  only  did  it  appear  to  be  of  service. 

One-tenth  grain  of  hydrochlorate  of  cocain  every  four  hours  for  a 
child  two  years  of  age  was  employed  in  twenty-three  dispensarv  and 
in  five  private  cases.  It  possesses  some  value  in  controlling  the 
severity  of  the  paroxysms,  but  the  results  were  not  sufficiently 
marked  to  warrant  its  further  use. 

Quinin  has  been  used  in  a  large  number  of  cases,  in  both  private 
and  out-patient  work.  I  find  that  great  benefit  may  be  derived  from 
its  use  if  a  large  amount  can  be  given.  Its  administration,  how^ever, 
is  attended  with  difficulties.  Twelve  to  twenty  grains  in  twenty- 
four  hours  are  required  for  pronounced  results  in  children  from  two 
to  six  years  of  age.  The  administration  of  such  a  large  amount  of 
this  well-known  drug  is  not  favorably  received  by  many  parents. 
Our  inability  to  make  it  palatable  is  a  serious  drawback  at  any  age, 
and  almost  excludes  its  use  in  the  very  young ;  furthermore,  in  the  very 
young  and  delicate,  it  is  apt  to  derange  the  stomach  and  produce 
vomiting.     If  given  in  solution  it  is  best  to  use  the  bisulphate  in 


326  CONTAGIOUS    DISEASES 

yerberzine  (Lilly).  In  older  children,  when  quinin  can  be  given  in 
sufficient  quantities  in  capsules,  the  improvement  as  to  the  number 
and  severity  of  the  paroxysms  is  sometimes  surprising. 

Belladonna  was  used  in  sixty  test  institution-cases.  It  was  be- 
gun at  the  height  of  the  paroxysmal  stage.  It  was  administered  to 
the  point  of  physiologic  effect  for  a  period  of  from  five  to  seven  days 
without  influencing  a  single  case  of  whooping-cough  in  the  slightest 
degree.  True,  the  cases  were  all  severe,  but  they  responded  promptly 
to  other  means  used  later.  The  children  were  all  between  three  and 
seven  years  of  age.  I  have  repeatedly  seen  these  children  with 
dilated  pupils  and  the  characteristic  belladonna  blush,  grasping  a 
crib  or  a  chair  for  support  during  a  paroxysm  that  furnished  an  ideal 
clinical  picture  of  the  disease. 

Equal  quantities  of  the  bromids  of  sodium,  ammonium,  and  po- 
tassium were  used  in  sixty  test  institution-cases.  The  results,  con- 
sidered from  all  standpoints,  were  better  than  with  any  of  the  means 
of  treatment  thus  far  referred  to.  The  severity  and  duration  of  the 
paroxysms  were  especially  influenced,  although  the  number  of 
seizures  was  practically  unchanged.  From  twelve  to  sixteen  grains 
in  twenty-four  hours  were  given  to  a  child  one  year  of  age.  When 
given  in  syrup  of  raspberry  on  a  full  stomach,  or  with  plenty  of  water, 
there  is  very  little  disturbance  attending  its  use.  For  a  child  two 
years  of  age,  sixteen  to  twenty-four  grains  may  be  given  daily, 

Antipyrin  was  used  later  in  sixty  test  cases  in  the  institution,  as 
well  as  in  out-patients  and  in  private  work,  I  have  given  antipyrin, 
combined  with  bromid  of  soda,  in  over  six  hundred  cases  of  pertussis. 
The  antipyrin  was  given  under  the  same  conditions  as  those  already 
referred  to,  combined  with  syrup  of  raspberry, 

i^.     Antipyrinae gr.  xviij 

Sodii  bromidi       gr.  xxx 

Syr.  rubi  idaei". " 5  v 

Aquae q.  s.  ad  oij 

M.     Sig. — One  teaspoonful  every  two  hours,  six  doses  in  twenty- 
four  hours,  for  a  child  fifteen  months  of  age. 

Antipyrin  is  readily  taken  and  easily  borne  by  the  stomach — two  very 
desirable  requirements  in  a  drug  that  is  to  be  given  to  a  child  for  a 
considerable  time.  It  is  not  depressing  when  given  with  any  degree 
of  intelligence — in  fact,  it  is  well  borne  by  children  when  given  in  good- 
sized  doses,  and  it  controls  whooping-cough  better  than  does  any 
other  drug  I  have  ever  used.  Its  beneficial  effects  are  as  follows: 
The  paroxysms  are  diminished  in  number  from  one-third  to  one-half 
without  any  amelioration  of  an  individual  seizure,  or  the  seizures  may 
be  less  severe  without  any  diminution  in  their  number.  In  some, 
both  the  severity  and  the  number  of  the  paroxysms  were  favorably 
influenced.     In  all  the  cases  the  effect  of  the  drug  was  beneficial, 

Antipyrin  gave  the  best  results  of  any  drug  used  alone.  The 
bromids  took  the  second  place.     We  then  combined  the  two  and  used 


WHOOPING-COUGH — PERTUSSIS  327 

them  in  forty  institution-cases.  We  soon  learned  that  the  two  drugs 
given  together  more  effectively  controlled  the  disease  than  when 
either  was  given  separately.  In  combination  they  gave  satisfaction 
in  the  large  number  of  cases  previously  referred  to.  At  the  out- 
patient department  of  the  Babies'  Hospital  we  use  the  drugs  com- 
bined in  the  form  of  a  compressed  tablet.  For  a  child  eight  months 
of  age  one-half  grain  of  antipyrin  with  two  grains  of  bromid  of  soda 
are  given  at  two-hour  intervals — six  doses  in  tw^enty-four  hours;  for 
a  child  of  fifteen  months,  one  grain  of  antipyrin  and  two  and  one- 
half  grains  of  bromid  of  soda  at  two-hour  intervals — six  doses  in 
twenty-four  horurs;  from  the  fourth  to  the  eighth  year,  two  grains 
of  antipyrin  and  five  grains  of  bromid  of  soda  at  two-hour  inter- 
vals— six  doses  in  twenty-four  hours. 

Codein  is  used  only  in  the  most  severe  forms  of  pertussis,  when 
other  means  fail  to  relieve  the  patient.  One  of  the  most  troublesome 
features  of  the  disease,  in  fact,  a  dangerous  feature,  is  the  wakefulness 
at  night  caused  by  repeated  attacks  of  coughing  and  vomiting.  When 
the  child  cannot  sleep,  I  give  codein  independent  of  the  other  treat- 
ment, whatever  it  may  be.  For  a  patient  five  years  of  age,  one- 
sixth  grain  is  given  at  bedtime  and  repeated  during  the  night  when- 
ever the  paroxysms  require  it.  For  a  child  from  eight  to  twelve  years 
of  age,  one-fifth  grain  may  be  given  at  bedtime  and  repeated  twice  if 
necessary.  For  a  child  from  two  to  three  years  of  age,  one-tenth  grain 
may  be  given  and  repeated  not  oftener  than  twice  during  the  night. 
The  drug  should  not  be  continued  longer  than  a  week  or  ten  days.  I 
have  never  seen  unpleasant  effects  follow  its  use. 

It  will  be  observed  that  the  drugs  of  value  in  whooping-cough  are 
the  sedatives.  It  is  well  known  that  by  the  prolonged  use  of  seda- 
tives their  effect  is  lost.  For  this  reason  I  have  found  it  wise  to  use 
what  may  be  called  '  *  interrupted  medication. ' '  For  five  days  the  anti- 
pyrin and  bromid  of  soda  are  given,  then  stopped,  and  full  doses  of 
quinin  are  given  for  five  days,  when  the  antipyrin  and  bromid  are 
resumed.  In  this  way,  giving  the  drugs  five  days  each,  we  continue 
with  advantage  for  a  month  or  six  weeks.  It  is  rarely  necessary  to 
continue  the  treatment  longer  than  six  weeks ;  usually  from  three  to 
four  weeks  is  sufficient.  Of  course,  the  child  will  whoop  after  that 
time,  but  the  active  stage  of  vomiting  and  severe  paroxysms  will  be 
over.  If  the  vomiting  can  be  controlled  in  an  attack  of  pertussis, 
and  if  the  patient  can  obtain  sufficient  sleep,  much  has  been  accom- 
plished. I  would  emphasize  here,  what  has  already  been  suggested: 
Do  not  begin  the  specific  whooping-cough  treatment,  whether  by  the 
administration  of  quinin,  antipyrin,  or  other  remedies,  until  the  spas- 
modic stage  is  at  its  height.  If  a  sedative  is  given  as  soon  as  a  diag- 
nosis is  made,  by  the  time  the  disease  reaches  its  height  tolerance  will 
have  become  so  established  that  the  drug  will  have  lost  not  a  little  of 
its  sedative  action.     If  medicines  must  be  given  during  the  earliest 


328 


CONTAGIOUS    DISEASES 


stage,  a  placebo  may  be  used.  The  Infant  Asylum  patients,  upon 
whom  the  best  of  our  observations  were  made,  received  distilled 
water  colored  with  compound  tincture  of  cardamom. 

Steam  inhalation  is  referred  to  only  to  call  attention  to  its  value 
when  used  in  connection  with  the  drug  treatment.  It  has  been 
of  great  service  in  the  very  young,  and  among  those  who  have 
complicating  bronchitis  and  bronchopneumonia.  I  prefer  the 
Arnold  steam  atomizer  (Fig.  35).  The  nozzle  is  placed  about  eight 
inches  from  the  face,  which  alone  is  exposed,  the  other  parts  of  the 
body  being  well  protected  by  a  rubber  sheet.  The  inhalations,  when 
taken  from  fifteen  to  twenty  minutes  every  two  hours,  often  give 
a  weakly,  cyanosed  patient  marked  relief.  I  have  used  wine  of  ipecac, 
creosote,  and  turpentine  in  the  water  thus  vaporized,  as  mentioned 

before;  but  I  am  not  convinced 
that  they  offer  any  advantage 
over  plain  steam. 

Fresh  air  is  of  immense  value 
as  a  means  of  relief  in  whooping- 
cough.  We  are  told  that  the 
child  rarely  coughs  when  out  of 
doors,  but  commences  as  soon 
as  he  is  brought  into  the  house, 
which  is  usually  overheated  and 
badly  ventilated.  In  nearly  all 
cases  the  cough  is  worse  at  night. 
This  may  be  explained  in  part 
by  the  absence  of  proper  ventila- 
tion in  the  sleeping  apartment. 
Many  out-patient  mothers  tell 
me  that  remaining  for  hours 
with  the  child  near  a  gas  tank  relieves  the  whooping-cough,  and  it 
doubtless  does.  There  is  a  vast  difference  between  the  comparatively 
pure  air  in  the  vicinity  of  the  gas  tank  and  the  air  of  the  average  tene- 
ment. I  always  encourage  the  gas-tank  treatment.  A  child  who  for 
any  reason  must  remain  indoors  should  not  be  allowed  to  remain  con- 
stantly in  one  room.  There  should  be  two  rooms,  every  window  in 
the  one  not  in  use  being  freely  open.  The  living-room  and  sleeping- 
room  should  be  kept  at  a  fairly  even  temperature — from  68°  to  70°  F. 
The  Kilmer  Belt. — A  few  years  ago  Dr.  T.  W.  Kilmer,  of  New 
York,  conceived  the  idea  that  a  belt  around  the  child's  body  producing 
firm  pressure,  would  support  the  abdomen  sufficiently  during  a 
coughing  paroxysm  to  prevent  vomiting.  The  Kilmer  belt  (Figs.  36 
and  37)  was  the  outcome.  I  have  used  the  belt  in  a  considerable 
number  of  cases;  at  first  with  a  great  deal  of  skepticism,  watching 
the  patients  upon  whom  it  was  used  at  my  clinics  at  the  out-patient 
department  at  the  Babies'  Hospital  and  at  the  New  York  Polyclinic, 


Fig.  35.— The  Arnold  Ste.\m  Atomizer. 


WHOOPING-COUGH — PERTUSSIS 


329 


where  records  were  kept  of  the  number  of  vomiting  seizures  in  twenty- 
four  hours,  for  three  days  before  applying  the  beh,  and  the  further 
record  after  the  belt  was  in  use,  together  with  the  statement  of  the 
mothers  and  oftentimes  of  the  children  themselves.  These  records 
convmced  me  that  the  belt  has  a  field  of  usefulness  in  the  management 
of  whoopmg-cough.  I  later  adopted  it  for  use  among  my  private  pa- 
tients. Like  most  remedial  measures,  however,  its  use  is  not  always 
attended  with  success.  I  have  applied  the  belts  without  the  slightest 
benefit  in  some  vomiting  cases.  Usually,  how- 
ever, it  is  of  service  in  relieving  the  vomiting. 
In  some  the  vomiting  has  entirely  ceased  after 
the  belt  was  applied.  I  believe'  it  should  be 
given  a  trial  in  every  severe  case,  particularly 
where  the  vomiting  is  a  very  prominent  symp- 


Fig.    36. —  The     Kilmer 
Belt. 


Fig.  37.— The  Kilmer  Belt  in  Position. 


tom,  and  in  infants  in  whom  the  drug  treatment  is  unsatisfactory. 
The  belt,^  which  has  been  improved  from  time  to  time,  is  made  of 
hnen,  with  pieces  of  rubber  elastic  at  those  portions  which  rest  against 
the  sides  of  the  child.  There  are  eyelets  in  each  end  for  the  purpose 
of  lacmg  the  belt  together.  It  is  best  to  apply  it  over  the  nether- 
most garment. 

"The  belt  is  made  by  J.  Jungmann,  New  York.     In  taking  a  measurement 

taken ''T";f'."H  1'^"  "'^^T"  '1'^?""^  ''''  "^"^^  prominent  parts  should  be 
taken.     This  with  the  age  of  the  child  should  be  sent  to  the  manufacturer. 


330 


CONTAGIOUS   DISEASES 


MEASLES 

Measles  is  a  disease  which  few  of  the  human  race  escape.  In  itself 
it  cannot  be  considered  a  dangerous  disease,  for  when  uncomplicated, 
it  is  almost  never  fatal.  On  account  of  its  tendency  to  respiratory 
complications,  however,  particularly  in  the  young  and  the  feeble,  it  is 
indirectly  one  of  the  most  fatal  diseases.  During  the  year  1906,  441 
deaths  due  to  measles  occurred  in  Greater  New  York — 58  more  than 
were  caused  by  scarlet  fever. 

Popular  Misconceptions. — Grave  errors  exist  among  the  laity," 
and  perhaps  among  a  few  physicians  also,  as  to  the  proper  manage- 
ment of  the  more  severe  exanthematous  diseases,  and  as  the  measles 
patients  suffer  most  from  this  failure  properly  to  appreciate  existing 
conditions,  it  is  not  out  of  place  to  speak  of  them  here. 

The  popular  conception  as  to  the  management  of  measles  is  that 
the  patient  should  be  warmly  wrapped,  given  hot  drinks,  and  kept 
in  a  dark  room  with  little  or  no  ventilation.  An  attack  of  measles 
renders  the  child,  for  the  time  being,  a  very  susceptible  subject  for 
bronchopneumonia.  The  younger  or  the  more  delicate  the  child, 
the  greater  the  danger.  The  dark  room  with  its  closed  windows  and 
doors  and  dust,  the  extra  wrappings  with  the  resulting  heat  "consti- 
pation," and  the  reduced  vitality,  do  much  to  prepare  the  way  for 
that  which  we  most  dread  in  an  attack  of  measles,  viz.,  a  possible 
bronchopneumonia ;  for  in  measles  one  danger-signal  is  up  constantly 
throughout  the  attack,  and  it  always  reads  pneumonia. 

Complications. — In  children's  institutions  today  measles  is  dreaded 
more  than  diphtheria  and  more  than  scarlet  fever,  for  the  reason  that 
when  an  epidemic  breaks  out,  because  of  its  marked  early  contagious 
characteristics,  it  means,  in  all  probability,  many  cases  and  many 
deaths.  In  an  epidemic  in  one  of  the  New  York  institutions  for  chil- 
dren, a  few  years  ago,  there  was  a  death-rate  of  40  percent  from 
measles  complicated  with  bronchopneumonia.  Having  been  through 
many  epidemics  of  measles  in  children's  institutions,  and  having  seen 
many  cases  in  private  and  complicated  cases  in  consultation,  I  am 
convinced  that  in  this  disease  we  have  an  illness  which  should  inspire 
much  greater  respect  on  the  part  of  the  physician  and  demand  the 
highest  intelligence  on  the  part  of  both  physician  and  the  family  in 
order  that  it  be  managed  to  the  best  interest  of  the  patient.  Sup- 
purative otitis  is  a  fairly  frequent  complication ;  nephritis  is  a  rare 
one. 

Pneumonia  is  an  infectious  disease.  In  measles  an  inflammation 
of  the  mucous  membrane  of  the  respiratory  tract  is  a  part  of  the  dis- 
ease. We  have  thus  prepared  for  us  a  most  favorable  soil  for  the 
development  of  pathogenic  bacteria  that  may  be  inhaled  through  the 
mouth  or  nose.  Given  a  dust-free  room,  advisedly  ventilated,  and 
we  would  have  comparatively  few  cases  of  measles-pneumonia. 


MKASLES  331 

Treatment. — General. — A  child  ill  with  measles  should  be  com- 
fortably clad  in  the  usual  night-clothes  and  kept  in  bed.  No  extra 
wraps  are  required ;  neither  is  it  desirable  to  keep  the  room  at  a  higher 
temperature  than  is  customary;  68°  to  70°  F.  is  a  suitable  room 
temperature.  There  are  many  gradations  of  Ught  between  glaring 
sunUght  and  utter  darkness.  Both  are  extreme,  and  one  almost  as 
undesirable  as  the  other.  It  is  my  custom  to  advise  that  a  window- 
shade  of  dark  green  be  lowered  within  one  foot  of  the  window-sill. 
The  light  brown  or  drab  shade  should  be  lowered  completely.  If 
the  shade  is  white  or  a  very  light  color  and  not  protected  by  a 
curtain  of  dark  material,  it  will  be  necessary  to  exclude  the  bright 
light  by  some  other  means. 

The  patient  should  be  put  on  a  reduced  diet.  If  bottle-fed,  the 
milk  mixture  should  be  diluted  at  least  one-half  bv  adding  boiled 
water,  the  same  quantity  being  given  as  in  health.  This  usually 
will  be  required  only  during  the  first  few^  days  of  the  acute  febrile 
stage.  Patients  with  measles  are  given  water  to  drink  freely  at  a 
temperature  not  lower  than  50°  F.  For  "runabout"  children,  eigh- 
teen months  of  age  and  over,  the  diet  as  suggested  for  the  sick  (see 
page  133)  should  be  given. 

There  should  be  one  evacuation  of  the  bowels  daily.  An  enema 
should  be  given  when  this  does  not  otherwise  take  place.  The  urine 
should  be  examined  for  albumin  every  second  day. 

During  the  waking  hours  the  eyes  should  be  generously  bathed 
every  hour  or  two  with  a  3  percent  solution  of  boric  acid,  using  old 
linen,  which  is  afterward  destroyed. 

Symptomatic. — The  temperature  of  uncomplicated  measles  is 
rarely  high  enough  to  call  for  special  interference.  If  it  should  have 
a  tendency  to  continue  above  104°  F.  for  eight  or  ten  hours  and  the 
child  be  uncomfortable  and  restless,  a  tepid  sponge-bath  may  be 
given,  the  duration  of  which  may  be  from  ten  to  twenty  minutes, 
and  repeated  at  intervals  of  two  or  three  hours.  Whether  the  fever 
demands  it  or  not,  the  patient  should  be  sponged  twice  a  day  with 
tepid  water  at  100°  F.  He  is  then  dried  and  an  appUcation  of 
cold-cream,  liquid  albolene,  or  olive  oil  is  made  to  the  entire  body. 
This  is  given  for  the  sole  reason  that  it  relieves  the  itching,  induces 
sleep,  aids  digestion,  reduces  the  temperature,  and  enables  the  child 
to  pass  through  the  disease  with  less  discomfort. 

Now  and  then  a  case  is  encountered  in  which  the  rash  is  slow  in 
appearing.  The  temperature  is  high,  104°  to  105°  F.,  the  skin  hot 
and  dry,  and  the  child  very  uncomfortable,  perhaps  delirious.  In 
such  patients  a  hot  bath,  105°  F.  to  110°  F.,  of  from  three  to  five 
minutes'  duration  will  often  bring  out  the  rash,  greatly  to  the  relief 
of  the  symptoms,  w^hich  may  have  been  of  an  urgent  character. 

The  cough  of  measles  during  the  active  period  of  the  attack  is  one 
of  the  annoying  features  of  the  disease,  and  some  relief  must  be 


332  CONTAGIOUS   DISEASES 

attempted,  particularly  if  the  child  is  kept  awake  at  night  by  it. 
The  ordinary  expectorants  alone  are  of  no  service  in  a  measles  cough. 
A  sedative  only  will  give  relief.  For  a  child  six  months  of  age,  from 
five  to  eight  drops  of  paregoric  may  be  given,  and  repeated  after  an 
interval  of  two  hours,  if  necessary.  The  following  combination  of 
paregoric  and  sweet  spirits  of  niter  is  often  of  service : 

I^.     Tincturae  opii  camphoratae gtt.  x 

Spirit!  etheris  nitrosi gtt.  iij 

M.     Sig. — One  dose;  to  be  repeated  every  two  or  three  hours,  for 
a  child  of  eighteen  months  or  older. 

From  the  first  to  the  second  year  ten  to  fifteen  drops  of  paregoric 
may  be  given  at  two-hour  intervals,  if  required,  or  one-half  grain  of 
Dover's  powder  may  be  used.  Usually,  it  will  be  necessary  to  give 
but  two  or  three  doses  of  the  sedative  during  the  night.  Should  the 
paregoric  or  Dover's  powder  be  objectionable  because  one  may  dislike 
to  give  opium  to  young  children,  from  three  to  four  grains  of  sodium 
bromid  in  two  drams  of  water,  repeated  as  required  every  hour  or 
two,  will  be  of  service  for  a  child  under  two  years  of  age.  From  the 
second  to  the  fifth  year  one  grain  of  Dover's  powder,  or  from  fifteen 
to  twenty-five  drops  of  paregoric,  or  j-q  to  ^  grain  of  codein,  may  be 
given  at  intervals  of  from  two  to  four  hours. 

If  bronchitis  develops  sufficiently  to  require  treatment,  as  it  does 
in  at  least  one-half  the  cases,  the  means  for  the  management  of  bron- 
chitis suggested  on  page  258  will  be  found  useful.  The  temperature 
of  a  child  ill  with  measles  should  be  taken  three  times  daily  and  the 
lungs  and  heart  should  be  examined  every  day.  It  is  my  custom  to 
keep  the  air  of  the  sick-room  moistened  with  vapor  during  the  entire 
illness.  Its  benefits  are  twofold.  It  relieves  the  cough,  as  it  is  more 
agreeable  to  the  congested  mucous  surface  during  the  early  stage,  and 
prevents  the  free  circulation  of  dust,  the  danger  of  which  has  already 
been  referred  to.  If  the  room  is  carpeted,  it  should  be  well  sprinkled 
with  water  before  sweeping.  It  is  much  better  if  the  floor  is  bare,  as 
the  broom  can  then  be  dispensed  with  and  a  damp  cloth  used  instead. 
The  length  of  the  quarantine  is  usually  from  twelve  to  sixteen  days, 
at  least  ten  days  of  this  time  being  spent  in  bed. 

Otoscopic  examination  should  be  made  every  second  day  until 
the  case  is  discharged.  In  the  event  of  a  sudden  rise  in  tempera- 
ture during  convalescence,  which  cannot  be  explained  by  the  con- 
dition of  the  intestines,  lungs,  or  throat,  such  an  examination  should 
be  made  by  an  expert. 

CHICKEN-POX— VARICELLA 

Chicken-pox  is  a  disease  for  which  very  little  treatment  is  re- 
quired. During  the  eruptive  period  and  until  the  stage  of  vesicula- 
tion  is  passed  and  crusts  have  formed,  it  is  well  to  keep  the  young 
child  in  bed.      Older  children  will  find  such  confinement  irksome. 


GERMAN   MEASLES — RUBELLA  333 

and  they  may  be  allowed  to  be  about  the  room,  but  should  not  be 
allowed  to  go  out  of  doors.  During  an  attaek  of  chicken-pox  the 
child  is  more  sensitive  to  exposure,  and  while  complications,  such  as 
nephritis,  are  rare,  one  of  the  worst  cases  of  acute  nephritis  which  it 
has  been  my  lot  to  treat  developed  as  a  sequela  of  chicken-pox. 
The  itching  is  the  most  annoying  feature  of  the  disease,  as  it  causes 
restlessness,  loss  of  sleep,  and,  through  the  child's  attempts  at  secur- 
ing relief  by  scratching,  opens  up  the  possibility  of  grave  skin  in- 
fections. In  out-patient  work  I  have  repeatedly  seen  extensive 
furunculosis  follow  an  attack  of  chicken-pox.  In  two  institution- 
cases  erysipelas  developed,  and  in  two  others  dermatitis  gangrenosa 
was  a  sequela.  During  the  stage  of  active  eruption  the  child  should 
not  be  given  a  tub-bath,  gentle  sponging  with  a  tepid  solution  of 
boric  acid — two  heaping  tablespoonfuls  of  boric  acid  to  one-half 
gallon  of  boiled  water — answering  the  purpose  of  cleanliness  for  a 
few  days.  After  the  daily  sponging,  and  several  times  during  the  day, 
the  areas  affected  are  anointed  with  a  10  percent  boric  acid  oint- 
ment, made  with  cold-cream  as  follows : 

I^.     Pulveris  acidi  borici gr.  c 

Unguenti  aquae  rosae q.  s.  ad   oij 

The  boric  acid  ointment  relieves  the  itching  to  a  marked  degree 
and  doubtless  is  of  value  in  preventing  local  skin  infection.  An 
equally  effective  remedy,  but  one  less  agreeable  for  domestic  use,  is  a 
lotion  composed  of  5  percent  ichth^ol  and  sterilized  olive  oil.  This 
is  applied  to  the  entire  body  twice  daily  after  the  bath.  Objections 
to  its  use  are  the  odor  and  the  staining  of  the  clothing  and  bed-linen. 
Permanent  scars  at  the  site  of  the  vesicles  are  so  rarely  seen  that  no 
special  precautions  are  required  on  this  account.  The  duration  of 
the  attack,  from  the  beginning  of  the  period  of  eruption  until  the 
crusts  fall,  is  usually  about  three  weeks.  The  child  should  be  con- 
sidered in  quarantine  and  not  allow^ed  to  come  in  contact  with  the 
unprotected,  until  the  skin  is  clear. 

GERMAN  MEASLES— RUBELLA 

German  measles  requires  ordinarily  very  Uttle  treatment.  About 
two  days  in  bed,  a  few  more  days  in  the  house  with  a  reduced  diet, 
and  free  bowel  action,  is  usually  all  that  is  needed,  recovery  being 
complete  in  from  six  to  eight  days  from  the  beginning  of  the  attack. 
The  enlargement  of  the  post-cervical  glands  and  the  associated  pain 
may  be  reheved  by  applications  of  a  25  percent  ichthvol  ointment  on 
strips  of  linen  firmly  held  in  position.  The  emplastrum  kaohni 
may  also  be  used  in  the  same  manner  with  equally  beneficial  re- 
sults. Where  either  is  used,  the  dressing  should  be  changed  every  six 
hours. 


334  CONTAGIOUS   DISEASES 


MUMPS ;  EPIDEMIC  PAROTITIS 

Mumps  is  a  contagious  disease  of  the  "runabout"  age  of  child- 
hood. The  seat  of  the  operation  of  the  infection  is  the  parotid  gland. 
One  or  both  glands  may  be  involved.  Often  the  involvement  of  one 
gland  is  three  or  four  days  in  advance  of  the  other.  The  period  of 
incubation  is  a  long  one — usually  from  two  to  three  weeks.  The 
duration  of  the  disease,  from  the  commencement  of  the  swelling  until 
it  has  completely  subsided,  is  about  ten  days.  It  is  rarely  longer 
than  this  when  both  glands  are  involved  at  the  same  time. 

Treatment. — During  an  attack  the  child  should  be  kept  in  bed 
until  the  temperature  is  normal.  He  should  remain  in  the  house 
until  the  swelling  has  entirely  subsided.  He  should  be  put  on  a 
reduced  diet  of  broths,  gruels,  and  milk,  as  in  any  illness  with 
fever.  Fruits  and  acids  should  not  be  given  because  of  the  discom- 
fort they  occasion  to  the  patient.  The  bowels  should  move  once 
daily.  When  this  does  not  occur,  citrate  of  magnesia  or  a  SeidHtz 
powder  should  be  given. 

The  temperature  rarely  requires  interference.  If  it  reaches  104° 
F.,  twenty  minutes'  sponging  with  one-fourth  alcohol  and  three- 
fourths  water  at  80°  F.  will  usually  control  it.  Relief  of  the  pain 
and  tension,  which  are  most  severe  in  some  cases,  is  best  secured  by 
warm  wet  dressings.  A  table  napkin  wrung  out  of  water  at  a  temper- 
ature of  from  110°  to  120°  F.,  and  placed  over  the  parts,  is  a  conve- 
nient method.  The  warmth  and  moisture  will  be  better  retained  if 
oiled  silk  or  rubber  tissue  is  placed  over  the  dressing.  The  appHca- 
tion  should  be  changed  every  twenty  or  thirty  minutes.  During  the 
night  or  at  other  times  when  the  frequent  changing  would  disturb 
the  patient  warm  camphorated  oil  on  a  piece  of  flannel  which  is 
bound  to  the  parts  will  usually  be  agreeable  to  the  patient. 

Complications. — Complications  in  mumps  are  rare.  Orchitis  is 
occasionallv  seen  in  boys,  but  it  rarely  occurs  if  the  patient  is  kept 
in  bed.  Infection  of  the  parotid  gland,  other  than  that  of  the  spe- 
cific poison,  is  extremely  rare.  I  have  never  seen  a  case  of  so-called 
mixed  infection.  Nephritis  is  a  rare  complication  in  mumps.  I 
have  seen  one  case  of  this  nature. 

Errors  in  Diagnosis. — Errors  in  the  diagnosis  of  mumps  occur 
very  frequently.  A  great  many  cases  of  acute  adenitis  are  diag- 
nosed as  mumps.  When  getting  the  history  of  the  previous  illnesses 
in  out-patient  or  private  work,  we  are  not  infrequently  told  that 
the  child  has  had  two  or  three  attacks  of  mumps,  which  means 
that  he  may  have  had  one  attack,  the  other  supposed  attacks 
being  acute  adenitis.  It  has  occurred  to  me  that  probably  some  of 
these  cases  which  were  diagnosed  as  mumps  were  due  to  an  infection 
which  had  extended  to  the  parotid  from  the  adjacent  lymph-glands. 


THE  URINE 

Tables  dealing  with  the  frequency  of  urination  and  the  specific 
gravity  of  the  urine  for  the  different  ages  of  childhood  are  neces- 
sarily inaccurate,  particularly  when  they  refer  to  children  under  one 
year  of  age. 

Urinary  Observations. — At  the  New  York  Infant  Asylum  a  few 
years  ago,  Dr.  George  T.  Myers,  at  that  time  resident  physician,  made 
a  series  of  investigations  under  my  direction  as  to  the  various  phases 
and  functions  of  the  newly  born  infant  which  differed  from  some  of 
the  observations  previously  recorded.  Among  other  observations  was 
one  as  to  the  time  of  the  first  micturition  after  birth.  Forty-five 
cases  cover  the  series.  It  was  found  that  the  time  varied  greatly. 
In  fifteen  it  occurred  simultaneously  with  birth;  in  ten,  in  less 
than  four  hours;  in  eight,  in  from  four  to  eight  hours;  while  the  re- 
mainder ranged  between  eight  and  eighteen  hours  after  birth.  In 
but  two  cases  was  it  longer  than  fourteen  hours.  Without  going 
into  detail  as  to  other  studies  made  of  the  urine  in  young  children,  it 
was  found  that  the  specific  gravity,  the  frequency  of  urination,  and 
the  amount  of  urine  passed  were  subject  to  wide  variations  within 
normal  limits.  These  various  features  depended  upon  whether  the 
child  was  breast-fed  or  bottle-fed,  whether  it  was  a  girl  or  a  boy,  and 
whether,  if  breast-fed,  the  mother  had  a  scanty  or  a  free  flow  of 
milk.  The  bottle-fed  always  passed  more  urine  than  the  breast-fed. 
The  quantity  of  urine  is  also  influenced  by  the  clothing  worn  and  by 
the  season  of  the  year. 

Normal  Variations. — Normal  variations  are  therefore  necessarily 
within  very  wide  limits.  One  child  will  pass  its  urine  every  thirty 
minutes  when  awake ;  others,  of  equal  health  and  age,  will  retain  it 
for  three  hours.  Before  the  child  takes  much  fluid,  particularly  in 
the  first  days  of  life,  from  two  to  five  ounces  is  probably  passed  in 
twenty-four  hours  with  a  specific  gravity  of  1.005  to  i.oio.  Infants 
urinating  very  frequently  are  apt  to  develop  into  bed-wetters  in  later 
life,  probably  owing  to  the  undeveloped  condition  of  the  bladder,  the 
size  of  that  viscus  remaining  small.  Other  than  this,  very  frequent 
urination  with  an  absence  of  signs  of  illness  is  of  no  significance  in  the 
young.  After  the  feeding  is  established,  the  specific  gravity  will 
range  from  1.003  to  1.012  from  the  second  week  to  the  second  year. 
A  baby  nine  months  old  will  pass  an  average  of  about  twelve  ounces 
of  urine  in  twenty-four  hours.  When  six  years  of  age,  from  sixteen 
to  twenty-five  ounces  will  be  passed  with  a  specific  gravity  under 
1. 01 5.     From  this  age  until  puberty  both  the  quantity  and  specific 

335 


336 


THE    URINE 


gravity  gradually  increase,  the  usual  range  in  specific  gravity  being 
from  i.oio  to  1.020. 

Method  of  Collecting  Urine. — The  collection  of  the  amount  voided 
in  twenty-four  hours  in  children  of  the  "runabout"  age  is  difficult, 
and  in  young  infants  well  nigh  impossible.  For  accurate  work 
the  specimen  should  be  obtained  by  the  catheter.  When  for  any 
reason  this  is  not  possible,  there  are  various  devices  for  collecting  the 
urine,  any  one  of  which  may  be  tried.  The  tying  on  of  a  wide- 
mouthed  bottle  or  a  condom  in  boys,  fastening  it  with  adhesive  strips 
to  the  body,  is  often  successful.  Absorbent  cotton  into  which  the 
child  urinates,  the  urine  being  expressed  from  it  into  a  bottle,  may 
be  used  for  either  boys  or  girls,  as  may  also  the  Chapin  collector 
(Fig.  38).  The  chief  disadvantage  of  any  of 
these  measures  is  the  certainty  of  contamina- 
tion. The  urine  so  collected  may  answer  for 
an  examination  for  albumin,  sugar,  or  the  renal 
elements,  but  is  useless  for  a  bacterial  study. 
From  the  second  to  the  third  year  conti- 
nence at  night  is  usually  established.  If  in- 
continence continues  after  the  third  year,  the 
case  should  be  looked  upon  as  abnormal  and 
receive  treatment  accordingly.  (See  Inconti- 
nence of  Urine,  page  338.) 


DIFFICULT  AND  PAINFUL  URINATION 
Painful  urination  is  of  frequent  occurrence 
in  infants  and  "runabout"  children.  It  may 
be  due  to  irritation  at  the  urethral  outlet  fol- 
lowing injury,  or  to  scalding  from  acid  urine, 
but  more  frequently  the  irritation  is  due  to 
lack  of  cleanliness  of  the  parts,  which  remain 
moistened,  and  inflammation  results. 

In  two  cases  I  have  found  calculi  in  the 
urethra.  Both  were  in  boys  about  five  years 
of  age.  By  far  the  greater  number  of  patients 
who  suffer  from  difficult  micturition  are  boys,  and  it  is  due  to  phimo- 
sis with  adhesions  and  retained  smegma.  Attention  to  the  external 
genitals  in  the  matter  of  cleanliness,  the  operation  of  circumcision, 
or  the  relief  of  adhesions  by  slitting  the  foreskin  and  freeing  the 
glans,  promptly  relieves  the  condition. 


Fig.    3S.  — Chapin    Urine 
Collector. 


RETENTION  AND  SUPPRESSION  OF  URINE 

In  using  the  above  terms  with  reference  to  diseases  of  the  urinary 
organs  it  is  well  to  appreciate  their  significance.  By  suppression  is 
meant  a  condition  of  anuria  in  which  no  urine  is  passed  into  the  blad- 
der, that  viscus  being  found  empty  on  catheterization.     Inretention, 


RETENTION    AND    SUPPRESSION    OF    URINE  337 

the  urine  is  secreted  by  the  kidneys  and  passed  into  the  bladder  but  is 
not  voided.  When  the  urine  is  not  voided,  we  must  always  ascertain 
whether  there  is  suppression  or  retention.  If  there  is  retention,  it 
can  usually  be  discovered  by  palpation  and  percussion.  In  fat  chil- 
dren a  positive  diagnosis  may  be  impossible  by  this  means.  In  any 
event,  when  in  doubt,  a  catheter  should  be  emploved.  For  infants 
under  one  year  of  age  a  soft-rubber  catheter,  No.  4  or  5  American, 
should  be  used.  If  suppression  is  diagnosed  and  treatment  by  diu- 
retics instituted,  when  there  is  simple  retention,  no  little  trouble  will 
result,  as  I  have  occasionally  seen. 

Suppression  of  the  urine  may  persist  for  hours  without  any  grave 
pathologic  condition  of  the  kidneys.  Chilling  of  the  skin  surface 
may  be  a  cause.  In  acute  gastro-intestinal  disorders  with  frequent 
vomiting  and  watery  stools  there  may  be  suppression  for  twenty- 
four  hours.  The  secretion  is  re-estabUshed  when  there  is  again  an 
available  fluid  to  be  added  to  the  circulation  from  the  digestive  tract. 
If  the  suppression  is  due  to  causes  of  a  grave  nature,  such  as  acute 
nephritis,  there  will  usually  be  signs  of  trouble  other  than  the  sup- 
pression, such  as  vomiting,  fever,  and  edema. 

Retention  may  result  from  an  injury  to  the  urethra,  or  in  girls 
from  vaginitis  or  in  boys  from  phimosis.  Impacted  stone  in  the 
urethra  was  a  cause  in  two  boys  seen  by  me.  Fortunately  in  each 
case  the  stone  was  located  near,  the  meatus  and  readily  removed. 
The  bladder  of  the  infant  and  young  child  is  very  readily  infected 
and  care  should  be  exercised  to  have  the  catheter  sterile  before  it 
is  used. 

Treatment. — The  immediate  relief  of  retention  is  by  catheteriza- 
tion. Further  treatment  consists  in  the  correction  of  the  exciting 
cause.  If  a  catheter  is  not  at  hand,  the  application  of  a  hot  stupe 
over  the  lower  portion  of  the  abdomen  and  the  genitals  may  be  suf- 
ficient to  stimulate  urination. 

Colon  Flushing. — Colon  flushing  in  suppression  of  the  urine  is  one 
of  the  most  effective  measures  of  relieving  this  very  urgent  condition. 
The  apparatus  required  and  the  methods  employed  will  be  found  on 
page  207.  If  the  temperature  of  the  patient  is  not  above  102°  F., 
the  normal  salt  solution,  at  a  temperature  of  110°  F.,is  advised.  I 
have  alwavs  found  the  flushing  more  effective  when  this  degree  of  heat 
was  used.  One  pint  is  introduced,  for  a  child  three  years  of  age.  In 
children  of  one  year  or  under,  from  four  to  eight  ounces  is  all  that  will 
be  retained.  It  must  not  be  repeated,  however,  oftener  than  once 
in  six  or  eight  hours,  as  the  colon  of  a  child  soon  becomes  intolerant 
of  the  injections  and  but  little  will  be  retained.  Repeatedly,  after 
the  first  injection,  the  kidneys  have  resumed  activity  when  all  other 
means  have  failed.  It  has  been  particularly  useful  in  cases  following 
or  accompanying  the  exanthemata,  where  there  was  an  acute  ne- 
phritis with  greatly  diminished  secretion  of  the  urine. 


338  THE   URINE 


INCONTINENCE  OF  THE  URINE ;  BED-WETTING ;  ENURESIS 

The  involuntary  discharge  of  urine  is  normal  in  the  young  infant. 
Urination  becomes  a  voluntary  function  at  a  later  age,  the  time  de- 
pending largely  upon  the  child's  training.  In  most  children,  with  the 
right  kind  of  management,  it  may  be  controlled  during  waking  hours 
by  the  tenth  month.  During  sleep,  it  continues  to  a  later  period, 
and  while  in  many  cases  it  may  be  under  perfect  control  at  the  com- 
pletion of  the  second  year,  I  do  not  regard  the  loss  of  control  as 
abnormal  until  the  third  year  is  completed.  If  during  the  second 
year  the  child  shows  a  tendency  to  frequent  urination  and  involuntary 
passage  of  urine  during  waking  hours,  w^ith  habitual  incontinence  at 
night,  it  is  my  custom  to  advise  preventive  measures. 

In  some  of  these  children  the  urine  is  very  acid  and  of  a  high  spe- 
cific gravity — 1.020  or  over.  In  such  cases  a  reduction  of  the 
quantity  of  the  highly  nitrogenous  food-stuffs  in  the  diet,  especially 
meat  and  eggs,  is  often  followed  by  improvement — the  eggs  and  red 
meat  being  given  alternately  not  oftener  than  every  second  day. 
Where  the  urine  is  normal,  the  quantity  of  fluids  given  during  the 
twenty-four  hours  is  reduced  from  25  to  50  percent  and  more  solid 
nourishment  substituted. 

When  the  incontinence  persists  during  waking  hours  at  the  com- 
pletion of  the  second  year,  or  during  sleep  at  the  completion  of  the 
third  year,  the  condition  is  regarded  as  abnormal  and  the  child  placed 
under  treatment. 

In  assuming  the  care  of  a  child  w^th  incontinence  our  first  step  is 
to  discover  the  cause  of  the  trouble.  With  this  object  in  view  the 
patient  is  examined  with  the  idea  of  discovering  any  peripheral  ab- 
normality which  may  have  a  bearing  on  the  disorder.  Thus  the 
incontinence  may  be  due  to  a  vaginitis  or  to  an  adherent  clitoris  in 
girls,  or  to  phimosis  in  boys;  it  may  be  due  to  thread-worms  in  the 
rectum,  to  constipation,  to  stone  in  the  bladder,  to  cystitis — a  very 
rare  condition,  and  to  hyperacidity  of  the  urine — a  very  common 
one.  The  diet  also  may  play  a  part.  The  use  of  highly  nitrogenous 
food  in  large  amounts,  or  a  diet  rich  in  sugar  may  lead  to  changes  in 
the  urine  sufficient  to  cause  the  trouble.  The  presence  of  adenoid 
growths  in  the  nasopharyngeal  vault  is  supposed  by  some  writers  to 
cause  enuresis.  As  a  result  of  the  diurnal  and  nocturnal  inconti- 
nence, the  bladder  may  never  have  developed  and  its  capacity  may 
be  greatly  reduced.  Obviously,  when  such  is  the  case,  incontinence 
will  be  noted  both  day  and  night. 

After  all  possible  dietetic  and  peripheral  causes  have  been  elimi- 
nated, about  90  percent  of  the  cases  remain.  These  are  due  to  a 
neurosis,  and  are  not  dependent  upon  any  discoverable  pathologic 
condition.     There  is  a  lack  of  development,  a  weakness  of  the  vesical 


INCONTINENCE    OF    URINE;     BED-WETTING;     ENURESIS  339 

sphincter,  and  a  lack  of  coordination  of  those  portions  of  the  sympa- 
thetic nervous  system  which  control  micturition. 

Treatment. — If  due  to  peripheral  causes  they  must  be  corrected 
and  the  general  physical  condition  of  the  child  improved,  although 
in  my  experience  the  deUcate  and  chronically  ailing  are  not  the  chil- 
dren who  are  the  greatest  sufferers.  By  far  the  larger  number  of  my 
patients  have  been  well-nourished  children  who  were  otherwise  nor- 
mal. Long-continued  incontinence  does  not  appear  to  affect  the  gen- 
eral health.  When  well  established,  the  condition,  untreated,  usually 
continues  until  the  child  is  eight  or  ten  years  of  age.  I  have  known 
of  a  few  cases  which  persisted  until  puberty. 

If  no  improvement  follows  the  removal  of  all  possible  dietetic 
and  peripheral  causes,  we  must  assume  that  we  have  an  idiopathic 
incontinence  to  deal  with.  If  the  case  is  of  several  months'  or  years* 
standing,  with  nightly  incontinence,  once,  twice,  or  three  times,  we 
must  acquaint  the  mother  with  the  fact  that  prolonged  treatment 
will  in  all  probability  be  required,  and  that  unless  her  active  and 
continued  cooperation  is  assured,  the  treatment  of  the  case  will  not 
be  undertaken. 

Illusirahve  Cases. — To  show  how  untiring  must  be  our  efforts, 
a  recital  of  an  early  experience  with  twelve  inveterate  bed-wetters 
may  not  be  without  interest.  Several  years  ago,  while  resident  phy- 
sician at  the  New  York  Infant  Asylum,  twelve  patients,  nine  boys 
and  three  girls,  ranging  in  age  from  six  to  ten  years,  were  selected  for 
treatment.  All  were  in  fair  health.  No  local  cause  for  the  enuresis 
could  be  discovered  in  any  of  them.  They  had  been  given  the 
usual  treatment  with  strychnin,  belladonna,  and  other  drugs  without 
improvement.  They  had  always  been  bed-wetters.  All  wet  the  bed 
two  or  three  times  during  the  night,  and  three  suffered  from  daily 
incontinence  as  well.  The  oldest,  a  boy  of  ten,  with  incontinence 
by  day  and  night,  pronounced  incurable,  had  been  returned  to  us 
from  the  West,  where  he  had  been  sent  by  The  Children's  Aid  Society. 

The  patients  were  put  to  bed  at  seven  o'clock  and  wakened  at 
ten,  to  urinate.  The  medication  suggested  below  was  used.  Symp- 
toms of  atropin  poisoning  occurred  in  three  in  the  form  of  a  typical 
belladonna  blush  and  excitement.  After  six  weeks  of  treatment 
there  was  slight  improvement  in  four.  One  or  two  nights  a  week 
would  be  passed  without  bed-wetting.  At  the  end  of  the  third 
month  the  lapses  were  but  once  or  twice  a  week.  Seven  were  prac- 
tically well  at  the  end  of  the  fifth  month,  rarely  wetting  the  bed.  The 
treatment  was  continued  two  months  longer,  when  the  dose  was 
reduced  one-half,  again  continued  for  two  months,  and  then  stopped, 
and  nine  months  after  final  discontinuance  there  had  been  no  return. 
The  remaining  five  cases,  all  over  six  years  of  age  and  including  all  the 
girls,  showed  but  shght  improvement  after  the  fifth  month  of  treat- 
ment, the  incontinence  being  of  almost  nightly  occurrence.     During 


340  THE    URINE 

the  next  three  months  the  improvement  was  gradual,  and  at  the  end 
of  the  eighth  month  incontinence  occurred  not  oftener  than  twice  a 
week,  and  during  the  tenth  month  it  was  only  occasional.  The  dose 
was  reduced  one-half,  and  after  one  year  of  continuous  treatment 
there  was  no  return  of  the  trouble.  The  atropin  was  stopped,  and 
six  months  later  the  cure  was  apparently  complete. 

These  cases  need  not  cause  discouragement,  as  they  were  invet- 
•erates,  all  over  six  years  old,  and  the  oldest  ten.  They  had  always 
wet  the  bed  and  had  resisted  all  previous  treatment. 

Frequently  a  treatment  of  from  four  to  six  weeks  or  even  for  a 
shorter  time  effects  a  cure.  The  child  receives  three  meals  daily. 
The  breakfast  and  dinner  correspond  to  the  age  of  the  child,  but  one 
should  emphasize  the  fact  that  red  meat  is  to  be  given  but  once  during 
the  twenty-four  hours.  The  supper,  which  should  not  be  later  than 
six  o'clock,  I  designate  a  "  dry  supper."  It  may  consist  of  any  cereal, 
such  as  rice,  hominy,  farina,  or  wheatena,  served  with  butter  and  sugar. 
If  this  is  not  well  taken,  a  small  quantity  of  both  sugar  and  milk  may  be 
added.  Permissible  articles  for  the  evening  meals  in  addition  to  the 
above  are:  ice-cream,  milk-toast,  blanc-mange,  raw  fruit,  jelly, 
stewed  fruit,  bread  and  butter.  Meat,  eggs,  or  heavy  foods  of  any 
kind  should  not  be  given  at  night.  At  four  o'clock  in  the  afternoon 
the  child  is  given  as  much  water  as  he  wishes,  but  no  fluids  after  this 
time  are  allowed,  other  than  a  little  milk  on  the  cereal.  The  abstinence 
from  all  fluids  after  4  p.  m.  will  at  first  be  a  hardship  for  some  children, 
and  they  may  be  allowed  a  small  quantity — three  or  four  ounces  of 
milk  or  water — with  the  evening  meal;  but  this  quantity  should 
gradually  be  diminished  until  at  the  end  of  a  week  it  will  not  be 
missed. 

The  child  should  be  as  lightly  covered  at  night  as  comfort  will 
permit.  There  is  less  tendency  to  incontinence  if  the  child  rests  on 
his  side  or  stomach.  Sleep  in  this  position  should  be  encouraged. 
In  inveterates,  where  every  possible  aid  is  brought  into  use,  I  have 
used  the  knotted  towel  as  a  means  of  keeping  the  child  off  his  back. 
A  knot  is  tied  in  the  middle  of  the  towel.  It  is  then  passed  around 
the  child  so  that  the  knot  will  rest  on  the  back.  If  it  is  long  enough, 
the  ends  of  the  towel  may  be  pinned  together  over  the  abdomen  like 
an  abdominal  binder.  When  the  child  attempts  to  rest  on  the  back 
the  knot  causes  discomfort  and  the  position  is  changed.  At  10  or 
II  o'clock,  when  the  person  in  charge  retires,  the  child  should  be 
taken  up  to  urinate. 

Drugs. — Without  a  strict  observation  of  the  above  measures, 
particularly  those  referring  to  diet  and  the  abstinence  from  water  after 
4  p.  M.,  drugs  are  of  no  value,  whatever  their  method  of  administra- 
tion. With  the  above  suggestions  carried  out,  we  have  one  remedy 
which  is  of  great  value,  and  that  is  belladonna.  For  convenience  of 
administration  I  prefer  the  alkaloid,  atropin.     To  get  the  full  benefit 


INCONTINENCE   OF   URINE;     BED- WETTING;     ENURESIS  34I 

of  the  treatment  in  severe  cases  it  must  be  pushed  till  we  obtain  the 
physiologic  effect,  as  shown  by  a  slight  dilatation  of  the  pupils.  Be- 
fore beginning  the  treatment  it  is  well  to  advise  mothers  that  a  red- 
ness of  the  skin  need  cause  no  alarm,  but  that  when  it  is  noticed  they 
should  discontinue  the  drug  until  further  instructions  are  given. 
The  atropin  is  administered  as  follows:  One  grain  is  added  to  an 
ounce  of  water;  one  ounce  of  water  contains  approximately  500 
drops,  so  that  one  drop  of  the  atropin  solution  would  contain  ap- 
proximately 5I0  grain  of  the  drug.  The  mother  is  given  a  chart 
containing  the  directions  for  administration,  which  for  a  child  five 
years  of  age  are  as  follows : 

1st  day 4  p.  M.,  0  drop          7  p.  m.,   1   drop 

2d  "  "  1      "  "  2  drops 

3d  "  "  2  drops  "  2      " 

4th  "  "  2      "  "  3      " 

5th  "  "  3      "  "  3      " 

6th  "  "  3      "  "  4      " 

7th  "  "  4      "  "  4      " 

8th  "  "  5      "  "  5      " 

The  child  is  given  one  drop  daily  at  4  and  7  p.  m.  for  every  year 
of  its  age.  Thus,  for  a  child  three  years  old  the  dosage  should  not 
be  greater  than  three  drops,  twice  daily ;  for  a  child  six  years  old  not 
over  six  drops,  twice  daily,  would  be  given.  It  may  be  well,  if  the 
case  is  not  under  close  observation,  to  make  a  more  gradual  increase 
in  the  dosage  so  as  to  avoid  the  possibility  of  unpleasant  physio- 
logic effects. 

It  is  never  advisable  to  exceed  these  doses  even  in  older  children, 
for  the  reason  that  they  are  sufficient  to  control  the  enuresis ;  and 
the  dilated  pupils  and  belladonna  blush  which  follow  the  increased 
doses  show  that  such  doses  are  unnecessary. 

The  tolerance  of  atropin  varies  considerably,  although  children 
usually  bear  it  very  well.  Now  and  then  a  child  is  treated  who 
cannot  take  more  than  two  drops  (2^0  grain)  daily.  To  one  boy 
eight  years  of  age  but  2^0  grain  could  be  given  twice  daily.  Pro- 
nounced benefit,  ordinarily,  will  not  be  observed  during  the  first 
week  or  two  of  treatment.  If  the  child  suffers  from  incontinence 
while  awake,  this  will  first  be  cured.  The  improvement  in  nocturnal 
incontinence  is  more  gradual  and  may  be  considerably  delayed. 
Thus,  no  improvement  whatever  may  be  seen  for  two  or  three  weeks. 
In  the  cases  cited  above  it  will  be  noticed  that,  in  three,  no  improve- 
ment occurred  until  the  sixth  week.  In  the  average  case  the  im- 
provement is  gradual.  Instead  of  wetting  the  bed  every  night  there 
will  be  nights  at  short  intervals  when  there  will  be  very  slight 
incontinence,  or  none  at  all. 

Usually  after  a  few  weeks'  treatment  the  incontinence  entirely 
ceases.     The  mistake  frequently  made  is  to  stop  the  atropin  at  this 


342  THE   URINE 

point.  When  this  is  done  there  is  usually  an  immediate  return  of 
the  trouble.  The  full  treatment  should  be  continued  until  the  child 
has  ceased  wetting  the  bed  for  at  least  two  weeks,  when  the  daily 
amount  of  atropin  should  be  reduced  one-half  and  kept  at  this  point 
for  six  weeks.  If  at  the  end  of  tw^o  months  from  beginning  treat- 
ment there  is  no  incontinence,  the  drug  may  be  discontinued,  but 
the  dietetic  regulations,  particularly  the  "dry  supper,"  should  be 
continued  for  three  months  longer.  It  must  be  remembered  that 
the  element  of  habit,  which  has  become  established,  is  hard  to 
overcome,  even  after  the  neurosis  and  the  sphincter  weakness  have 
been  corrected. 

Strychnin  and  tincture  of  cantharides  have  been  advocated  by 
pediatric  writers.  In  weak,  poorly  nourished  children  strychnin 
may  be  added  to  the  iron  or  oil  tonics,  and,  as  a  tonic,  be  of 
service  in  improving  the  general  condition  of  the  patient,  and 
indirectly  be  an  aid  in  the  treatment  of  the  enuresis.  When  in- 
continence occurs  only  during  the  day,  the  dietetic  regulations  are 
the  same,  with  the  exception  that  the  fluids  allowed  need  not  be  cur- 
tailed unless  the  quantity  is  excessive.  The  dosage  of  atropin  is  the 
same,  but  the  time  of  administration  should  be  changed  to  after 
breakfast  and  after  luncheon,  instead  of  at  4  and  7  p.  m.  In  addition 
to  the  atropin,  strychnin  should  always  be  given  in  cases  of  inconti- 
nence by  day,  as  a  lack  of  development  or  a  relaxation  of  the  sphincter 
is  more  of  a  factor  with  them  than  is  failure  of  nerve  coordination. 

A  fact  to  be  taken  into  consideration  in  making  a  prognosis  as  to 
the  probable  duration  of  the  treatment  in  a  given  case  is  the  size  of 
the  bladder,  since  a  child  who  has  suffered  from  incontinence  both 
by  day  and  night  may  have  a  small  and  contracted  bladder  because  of 
lack  of  development  from  disuse.  In  one  of  my  cases,  in  a  girl  five 
years  of  age,  the  bladder  had  a  capacity  of  but  one  ounce.  The 
most  reliable  means  of  determining  the  size  of  a  bladder  is  by  meas- 
uring the  amount  of  sterile  water  which  can  be  introduced  through  a 
catheter. 

ALBUMINURIA 

Albuminuria  may  be  either  transient,  cyclic,  febrile,  or  paroxysmal, 
these  terms  indicating  the  different  conditions  under  which  albu- 
min is  found  in  the  urine.  Aside  from  the  albumin,  there  may 
be  no  indication  of  organic  kidney  disease,  either  clinically  or  micro- 
scopically. In  children  the  presence  of  albumin  without  other  signs 
of  trouble  is  of  much  greater  import  than  is  a  similar  condition  in 
adults.  The  absence  of  proof  of  a  kidney  lesion  does  not  mean  that 
such  a  process  may  not  exist.  My  own  experience  with  cases  of  so- 
called  functional  albuminuria  has  not  been  a  particularly  pleasant 
one. 

More  or  less  persistent  albuminuria,  regardless  of  its  association 
with  muscular  exertion  or  mental  excitement,  means  that  a  tempo- 


ACUTE  .NEPHRITIS 


343 


rary  change  is  taking  place  in  the  renal  epithelium.  Frequent  repe- 
tition of  such  processes  readily  leads  to  organic  changes,  and  I  am 
always  disturbed  by  the  presence  of  albumin,  as  I  consider  the  con- 
dition one  not  to  be  lightly  regarded.  One  of  my  cases,  now  under 
treatment,  shows  a  trace  of  albumin  after  eating  an  egg,  and  in  three 
of  my  cases,  a  diet  rich  in  meat  and  eggs  will  invariably  be  followed 
by  albuminuria. 

Treatment. — The  management  of  these  cases  involves  the  dis- 
covery and  removal  of  the  source  of  the  irritation.  If  caused  bv 
emotion,  exertion,  or  diet,  a  correction  of  the  child's  daily  habits 
should  be  made  along  rational  lines.  I  require  these  patients  to  be 
given  a  diet  free  from  eggs,  while  red  meat  is  allowed  not  oftener 
than  twice  a  week.  They  are  to  avoid  sudden  exposure  to  cold,  to 
wear  flannel  next  to  the  skin  nine  months  in  the  year,  and  light- 
weight silk-and-wool  undergarments  during  the  hot  months.  They 
are  not  allowed  to  indulge  in  hard  play.  Baths  below  80°  F.  are 
not  to  be  given  them.  Ocean  bathing  is  prohibited.  A  salt  bath 
(page  31),  followed  by  a  brisk  friction  with  a  coarse  towel,  is  given 
at  bedtime.  The  activity  of  the  skin  is  thus  insured.  The  bowels 
are  kept  open  by  the  free  use  of  fruits  and  the  malted  foods.  If  a 
laxative  is  required,  salines  are  preferred.  The  case  should  be 
under  observation,  the  above  precautions  observed,  and  the  urine 
examined  at  intervals  of  two  or  three  months  for  one  year  after  the 
last  negative  examination  for  albumin. 

ACUTE  NEPHRITIS 

Nephritis,  in  common  with  many  other  ailments  of  children,  may 
be  either  mild  or  severe.  It  may  be  so  severe  as  to  cause  death  in  a 
few  hours  or  so  mild  as  to  pass  unrecognized.  The  disease  is  rarely 
primary,  being  usually  due  to  some  systemic  infection.  The  treat- 
ment of  the  severer  forms  of  nephritis  is  often  open  to  the  most  em- 
phatic criticism,  reflecting  as  it  does  the  present  methods  of  the 
schools,  in  their  advocacy  of  forced,  indiscriminate  water-drinking, 
the  exclusive  milk  diet,  and  the  more  or  less  indiscriminate  use  of 
diuretic  drugs.  Every  one  of  these  measures  is  capable  of,  and  has 
been  productive  of,  no  little  harm.  Too  great  emphasis  has  been 
placed  upon  forcing  the  kidneys  to  act  and  too  little  upon  the  neces- 
sity of  reHeving  them  of  the  work  for  which  they  are  temporarily 
incapacitated.  The  advocacy  of  drinking  large  amounts  of  water 
when  the  kidneys,  distended  with  blood  and  the  tubules  obstructed, 
are  secreting  but  very  little,  does  nothing  but  harm.  Under  similar 
conditions,  heart  stimulants,  such  as  digitaUs,  which  forces  more 
blood  into  the  kidneys,  necessarily  make  a  bad  condition  w^orse. 

Treatment  of  Mild  Cases.— In  treating  nephritis,  there  are  several 
factors  to  be  kept  in  mind.  Because  a  case  is  mild  it  should  never 
be  given  scant  attention.     Nephritis  in  a  child  may  be  most  insidi- 


344  THE    URINE 

ous  in  its  course.  The  mildest  case,  while  not  treated  in  all  respects 
like  a  more  severe  one,  should  be  given  every  possible  attention  as  to 
rest  in  bed  and  diet,  for  through  neglect,  even  for  a  very  few  hours, 
it  may  become  most  severe. 

A  child  with  nephritis  must  be  kept  in  bed  with  the  temperature 
of  the  room  at  about  70°  F.  He  should  be  protected  from  drafts  of 
cold  air.  Silk,  a  mixture  of  silk  and  wool,  or  flannel  should  be  worn 
next  to  the  skin. 

The  nutrition  of  the  patient  is  to  be  maintained  by  food  which 
will  not  add  to  the  existing  trouble.  We  are  told  in  the  books  that 
nitrogenous  food,  such  as  meat  and  eggs,  is  to  be  avoided  in  order  to 
relieve  the  kidneys  from  the  work  of  the  secretion  of  urea  and  cre- 
atinin,  and  yet  often  we  are  advised  in  the  very  next  line  to  give  a  full 
milk  diet,  which  in  a  child  from  five  to  ten  years  of  age  means  from 
two  and  one-half  to  three  quarts  daily,  which,  it  will  be  remembered, 
contains  4  percent  of  nitrogenous  food  proteid.  A  diet  necessitating 
that  large  amount  of  nitrogenous  waste  (by-products)  will  have  to  be 
excreted  by  the  kidneys.  In  order  to  maintain  the  nutrition  of  the 
patient,  proteid  is  necessary,  and  may  be  supplied  by  the  use  of  a 
moderate  amount  of  milk.  For  a  child  under  five  years  of  age,  from 
sixteen  to  twenty  ounces  of  full  milk  should  be  given  daily — never 
more  than  twenty  ounces.  This  is  diluted  with  equal  parts  of 
cereal  gruel.  No.  i  or  2,  wdth  the  addition  of  one  teaspoonful  of 
sugar  (see  formulary,  page  124),  and  given  in  quantities  of  from  six 
to  ten  ounces  at  four-hour  inter\^als.  This  supplies  all  the  nourish- 
ment necessary  for  a  patient  of  this  age.  In  order  that  the  diet  may 
not  become  monotonous  to  the  child  and  cause  loss  of  appetite,  as 
is  almost  always  the  case  when  full  milk  is  used,  the  taste  of  the  food 
may  be  changed  by  the  use  of  cereal  gruels  of  different  kinds. 
Broths  and  beef  extracts  are  not  given  because  of  their  creatinin 
content.  Zwieback  and  butter,  stale  bread  and  butter,  prune- juice, 
thin  apple  sauce,  and  orange-juice  may  be  given  in  order  to  improve 
the  digestion  and  add  variety  to  the  diet.  Inasmuch  as  milk  cannot 
be  taken  at  the  same  time  as  fruit  by  many  patients,  it  may  be  given 
between  meals  or  wdth  a  plain  meal  gruel. 

A  patient  with  nephritis,  no  matter  how  mild,  should  have  two 
movements  daily.  These  should  be  rather  loose.  The  use  of  the 
fruit-juices  may  be  sufficient  to  keep  the  bowels  relaxed.  If  a  laxa- 
tive is  necessary,  citrate  of  magnesia  or,  in  very  young  children  and 
infants,  milk  of  magnesia  may  be  given  in  such  doses  and  at  such 
intervals — either  of  twelve  to  twenty-four  hours — as  may  be  neces- 
sary to  produce  the  desired  results.  Twenty-four  hours  should  not 
pass  without  an  evacuation  of  the  bowels.  The  patient  should 
always  have  an  enema  at  bedtime,  if  no  passage  has  taken  place  dur- 
ing the  preceding  twenty-four  hours. 


ACUTE    NEPHRITIS  345 

There  should  be  a  warm  sponge-bath  daily,  the  body  being 
sponged  and  dried  in  sections  under  a  flannel  blanket. 

Prophylaxis. — If  during  scarlet  fever  or  any  of  the  infectious  dis- 
eases the  physician  takes  the  precaution  of  having  nitric  acid  and  a 
few  test-tubes  at  the  home  of  the  patient,  so  that  the  urine  may  be 
tested  for  albumin  at  each  visit,  with  a  reasonably  frequent  micro- 
scopic examination  at  his  office,  a  nephritis  may  be  detected  before 
the  more  active  clinical  signs  of  the  disease  appear,  and  thus  by  plac- 
ing the  patient  promptly  under  the  above  management,  usuall}-  but 
little  trouble  will  be  experienced.  In  fact,  in  a  majority  of  the 
cases  the  above  suggestions  are  all  that  are  necessary  to  carry  the 
patient  safely  through  an  attack,  if  the  kidney  involvement  is  detected 
early  and  if  diuretic  drugs  are  omitted  from  the  treatment.  The  use 
of  additional  measures  for  the  more  severe  cases  will  depend,  to  a 
considerable  extent,  upon  the  individual  case. 

Treatment  of  Severe  Cases. — When  there  is  fever  with  partial 
suppression  of  the  urine,  only  one-half  the  usual  quantity  being 
passed  and  that  loaded  with  albumin,  blood,  and  casts,  with  per- 
haps beginning  edema,  colon  flushings  (page  496)  with  a  normal  salt 
solution  at  a  temperature  of  110°  F.  are  to  be  used.  The  flushings 
have  the  effect  of  increasing  the  functional  activity  of  the  kidneys. 
For  a  child  from  five  to  ten  years  of  age,  one  pint  of  the  warm  saline 
solution  may  be  thrown  into  the  colon.  An  effort  should  be  made  to 
have  the  child  retain  it  by  having  him  rest  on  his  left  side  with  the 
buttocks  elevated  on  a  pillow.  In  young  children  from  eight  to 
twelve  ounces  may  be  used,  and  in  infants  under  nine  months,  from 
four  to  six  ounces  is  all  that  we  may  hope  to  have  retained.  The 
flushings  should  not  be  repeated  oftener  than  at  twelve-hour  inter- 
vals, unless  the  condition  is  urgent,  as  an  intolerance  of  the  parts  is 
readily  brought  about  by  too  frequent  manipulations. 

If  there  is  a  hot,  dry  skin  with  a  tendency  for  the  temperature  to 
remain  above  102°  F.,  tincture  of  aconite  is  given  in  small  doses. 
For  a  child  three  years  of  age,  one-half  drop  is  given  at  two-hour 
intervals.  Older  children  may  be  given  one  drop  at  a  dose.  It  is 
rarely  wise  to  increase  it  above  two  drops  at  two-hour  intervals  even 
in  children  above  ten  years  of  age.  Only  sufficient  should  be  given 
to  produce  a  slight  diaphoresis,  for  by  keeping  the  skin  constantly 
moist  the  blood-vessels  of  the  kidneys  are  relieved  of  the  tension  to 
which  they  have  been  subjected. 

In  the  severer  forms  with  edema  or  anasarca,  cases  in  which  but 
two  or  three  ounces  of  urine  are  passed  daily,  more  active  measures 
will  be  required.  In  these  urgent  cases  the  diet  should  consist  tem- 
porarily of  thin  gruels  of  barley,  granum,  or  rice  (No.  i),  with  sugar 
added  to  make  them  more  palatable,  and  diluted  fruit- juices  given 
between  the  feedings.  In  a  carbohydrate  diet  there  are  no  by- 
products irritating  to  the  kidney.     Water  should  be  given  scantily. 


346  THE    URINE 

sufficient  fluids  being  given  in  the  food.  Active  measures  to  increase 
the  diaphoresis  and  thus  reUeve  the  kidneys  must  be  instituted. 
The  best  means  of  doing  this  is  by  the  use  of  hot  colon  flushings,  hot 
packs,  and  hot  baths.  In  these  cases  it  is  by  attempts  at  forcing 
the  kidneys,  by  the  use  of  digitahs  and  the  alkaUne  diuretics,  that  we 
do  an  immense  amount  of  harm.  Digitahs  drives  more  blood  into 
the  kidneys  and  thus  increases  the  congestion.  The  alkaline  diuretics 
disturb  the  stomach,  which  is  already  showing  signs  of  food  intoler- 
ance. Colon  flushings  at  i  io°  F.  are  now  to  be  used  every  six  hours. 
This  is  probablv  one  of  the  most  valuable  means  we  possess  for  re- 
lieving the  congestion  of  the  kidney  and  inducing  a  flow  of  the  urine. 

Heat,  either  drv  or  moist,  is  to  be  brought  immediately  into  use 
in  order  to  stimulate  the  skin  to  vigorous  action.     Both  dry  heat  and 
moist  heat  have  their  advocates.     Placing  a  child  in  a  warm  bath  at 
105°  F.,  keeping  him  there  for  a  few  minutes, 
drying  rapidly,  and  immediately  putting  him 
into  bed,  surrounded  by  hot-water  bottles,  will 
usually  produce  diaphoresis.     A  thermometer 
should  be  placed  under  the  bed-clothing  so 
that  excessive  heat  may  readily  be  detected. 
I  have  seen  pronounced  weakness  produced 
by  excessive  heat  used  for  such   a   purpose. 
The  child  should  not  be  allowed  to  rest  in  a 
temperature   higher  than    120°  F.,   and   this 
should  not  continue  for  over  ten  minutes,     A 
temperature  of   105°  F.   or   110°  F,   may  be 
maintained  for  an  hour  if  necessary.     If  the 
packs  are  used,  they  may  be  repeated  once 
^'"^tus'^f^th'e    k'ilmI^r     ^^  ^^^  hours.      The  disadvantages  of  a  hot 
Croup  Kettle.  bath  are  duc  to  the  fact  that  it  necessitates 

considerable  handling,  which  to  some  pa- 
tients is  a  cause  of  no  Uttle  excitement.  In  such  cases,  dry  heat 
may  be  substituted.  The  patient  is  warmly  clad  in  flannels  and 
hot-water  bottles  are  placed  near  him.  This  mav  be  sufficient  to 
induce  perspiration,  A  device  which  I  use  consists  of  a  funnel 
attached  to  a  one-inch  brass  pipe  which  is  bent  in  the  middle  to  a 
right  angle  and  which  conducts  the  warm  air  under  the  bed-clothing. 
The  heat  is  generated  by  a  kerosene  lamp,  over  the  top  of  which  an 
inverted  funnel  is  placed  at  a  sufficient  distance  to  allow  combustion 
to  take  place.  The  Kilmer  croup  kettle  has  an  appliance  which 
may  be  used  for  this  purpose  (Fig.  39). 

While  a  free  secretion  of  urine  is  desired  in  these  cases,  w^e  must 
not  be  content  with  that  alone.  Uremia  may  occur  even  while  the 
normal  amount  of  urine  is  being  passed.  A  quantitative  test  for 
urea  should  be  made  in  all  severe  cases  in  order  to  determine  the 
amount  excreted.     Normal  human  urine  contains,  roughly  speaking, 


ACUTE    NEPHRITIS  34 


2  percent  of  urea,  which  occasionally  in  health  rises  to  3  per  cent. 
Approximately  0.5  gram  of  urea  is  excreted  per  kilogram  of  body- 
weight.     The  proportion  in  children  is  relatively  higher.^ 

Treatment  of  Uremic  Convulsions.— Vomiting  is  one  of  the  first 
symptoms  of  uremia.  When  it  occurs,  all  food  should  be  temporarily 
withheld  from  the  stomach  and  nutrient  enemata  given  by  rectum. 
Completely  peptonized  skimmed  milk  is  our  best  means  of  nutrition, 
from  four  to  twelve  ounces  being  given  every  four  to  six  hours.  It 
is  best  to  give  large  quantities  at  long  intervals — every  six  hours  is 
best,  as  the  manipulations  with  the  tube  have  a  tendency  to  produce 
intolerance  on  the  part  of  the  gut.  The  tube  should  be  introduced 
at  least  eight  inches  into  the  bowel  and  the  solution  used  should  be 
lukewarm.  A  temperature  of  95°  or  100°  F.  will  best  be  retained. 
In  addition  to  the  use  of  colon  flushings  and  external  heat,  uremic 
convulsions  should  be  controlled  with  chloroform  or  the  rectal  ad- 
ministration of  the  bromids  or  chloral.  For  a  child  under  three  years 
of  age,  from  two  to  three  grains  of  chloral  may  be  given  with  eight 
grains  of  bromid  of  soda.  After  the  third  year,  three  grains  of 
chloral  may  be  used  with  from  eight  to  fifteen  grains  of  bromid 
of  soda.  It  is  best  retained  when  given  in  at  least  four  ounces  of 
mucilage  of  acacia  or  skimmed  milk,  the  enema  being  repeated  in 
four  or  six  hours. 

When  heart  stimulants  are  required,  tincture  of  strophanthus  is 
usually  given — from  one  to  two  drops  at  two-hour  intervals  to  a 
child  under  three  years  of  age.  After  this  age,  from  two  to  three 
drops  may  be  given.  Digitalis  is  sometimes  used  as  a  heart  stimulant 
during  convalescence,  after  the  secretion  of  the  urine  has  been  estab- 
lished. 

Convalescence. — Convalescence  is  often  tedious  in  these  cases. 
The  child  should  not  be  allowed  to  be  out  of  bed  until  albumin  has 
disappeared  from  the  urine.  For  at  least  six  months  after  an  attack, 
the  urine  should  be  examined  weekly.  Light-weight  woolens  should 
be  worn  next  to  the  skin  during  the  entire  year  and  every  effort  made 

'R.  Bradford,  in  AUbutt's  "System  of  Medicine"  : 

Amount   of    Urea    Excreted   on  the    Basis    of  0.5  Gram  per  Kilogram. 

1   vear       ^  ^"^^     ^'^^   "^-^45  gms.  in  24  hrs. 

'  y^""'      \Girls     8.24* 4.12     gms.  in  24  hrs. 

3  years     1 5?^^   ^"^-^"^    "O^  g"is.  in  24  hrs. 

^  years     ^  Girls   13.60* 6.80  gms.  in  24  hrs 

7   years      ^  ^"^'^  ^2.44   11.22  gms.  in  24  hrs. 

years      ^  ^^^j^   21.78* 10.89  gms.  in  24  hrs 

10  years     f  ^T  o^-.i " ^^'^^      gms.   in  24  hrs. 

^  \  Girls   29.0/* 14.535  gms.  in  24  hrs. 

13  years     ( ^"f  1??^^ 20.02     gms.  in  24  hrs. 

\  Girls   41.36* 20.68     gms.  in  24  hrs. 

16  years     (  ^^f  56.09   28.045  gms.  in  24  hrs. 

■^  \  Girls   51.24* 25.62     gms.  in  24  hrs. 

*  Figures  of  Boas,  quoted  from  Holt. 


348  THE    URINE 

to  protect  the  patient  from  sudden  exposure  to  the  influence  of  cold 
air.  With  the  advent  of  future  illness  with  fever,  even  though  it  does 
not  occur  for  a  year  or  two  afterward,  unusual  precautions  should  be 
taken  to  protect  the  child,  in  view  of  a  possible  reinvolvement  of  the 
kidneys  with,  possibly,  a  resulting  chronic  nephritis.  Meat  and  eggs 
should  be  given  scantily  for  a  year  after  an  attack.  Exercise  calling 
for  great  muscular  effort  should  not  be  allowed  for  a  considerable  time, 
at  least  for  a  year  after  all  trace  of  the  nephritis  has  disappeared.  I 
advise  that,  when  possible,  the  winter  after  an  acute  attack  be  spent 
in  a  warm  climate,  such  as  that  of  Florida  or  Lower  California. 

Scarlatinal  Nephritis. — A  form  of  acute  nephritis  which  deserves 
particular  attention  occurs  early  in  malignant  scarlet  fever.  The 
onset  is  very  abrupt.  But  little  urine  is  passed,  and  this  is  filled 
with  albumin  and  casts  and  blood.  In  a  recent  case  complete  sup- 
pression occurred  without  previous  warning  and  the  child  died  in 
thirty-six  hours,  the  duration  of  the  entire  illness  being  but  seventy- 
two  hours.  There  was  no  edema.  The  child  became  comatose  and 
died  from  the  uremia  and  the  intense  scarlatinal  poisoning.  In  these 
cases  repeated  hot  baths  and  packs,  105°  to  110°  F.,  should  be  used 
in  spite  of  the  high  temperature  which  is  usually  present.  Frequent 
hot  colon  flushings,  110°  F.,  should  also  be  given.  Heart  stimulants 
hypodermatically  may  be  of  value.  The  prognosis  in  these  cases 
is  very  unfavorable. 

CHRONIC  DIFFUSE  NEPHRITIS 

This  disease  is  rarely  seen  in  children  under  three  years  of  age, 
and  it  is  almost  invariably  the  result  of  an  acute  process  which  ran  its 
course  unrecognized,  or  of  faulty  management  following  an  acute 
nephritis.  The  following  history  is  quite  a  common  one :  A  patient 
who  came  under  my  care  three  years  ago  with  chronic  nephritis  gave 
a  history  of  having  had  three  distinct  acute  attacks  during  the  pre- 
vious four  years,  with  inter^^als  of  apparent  health.  The  urine  had 
not  been  examined  during  these  intervals  nor  had  she  had  the  ad- 
vantages of  proper  treatment. 

Treatment. — The  management  of  chronic  diffuse  nephritis  in 
children  resolves  itself  into  care  in  four  respects:  diet,  cHmate,  baths, 
and  exercise. 

If  the  patient  is  confined  to  the  bed,  the  diet  should  be  the  same 
as  suggested  under  acute  nephritis.  One  quart  of  milk  may  be  given 
daily.  If  the  child  is  up  and  about,  meat  may  be  given  once  every 
second  day.  Eggs  should  be  excluded.  In  other  respects  the  diet 
should  be  simple,  as  outlined  for  well  children  (page  128),  this  being 
ample  for  nutrition. 

The  child  should  receive  one  warm  bath — 95°  to  100°  F. — daily, 
followed  by  a  brisk  friction  with  a  dry  towel. 

An  outdoor   life  is  of  decided   advantage;    exertion,   however, 


GLYCOSURIA 


349 


should  not  be  allowed  to  the  point  of  fatigue.  Contests  or  stress  of 
any  kind,  mental  or  physical,  should  not  be  permitted. 

If  possible,  the  child  should  spend  the  colder  months  in  a  climate 
which  is  not  subject  to  sudden  or  wide  variations  in  temperature. 
The  climate  furnished  by  Florida  or  Lower  California  is  advocated 
when  the  parents  are  financially  able  to  give  the  patient  the  benefit 
of  it.  If,  however,  he  must  be  kept  in  his  home,  which  does  not  offer 
the  advantages  of  an  equable  climate,  great  care  should  be  exercised 
in  preventing  sudden  chilling  of  the  skin  surface.  Woolens  should 
be  worn  next  to  the  skin  at  all  seasons  of  the  year.  Frequent  exami- 
nations of  the  urine  should  be  made,  not  only  for  albumin  and  casts, 
but  for  urea  as  well.  Sudden  attacks  of  uremia  may  occur  even 
while  the  patient  is  passing  an  excessive  amount  of  urine. 

Chronic  interstitial  nephritis  is  very  rare  in  children.  I  have  seen 
one  case  in  a  patient  ten  years  of  age  who  had  been  ill  two  years.  He 
was  passing  a  large  daily  amount  of  urine — 60  to  90  ounces — an  ex- 
amination of  which  showed  a  specific  gravity  of  1.002.  There  was 
but  a  trace  of  albumin.     The  boy  died  in  a  few  weeks  of  acute  uremia. 

GLYCOSURIA 

Temporary  glycosuria  or  dietetic  glycosuria  is  of  frequent 
occurrence  and  is  of  little  significance.  It  usually  means  that 
more  sugar  is  being  taken  than  can  be  cared  for  by  the  economy, 
and  with  a  discontinuance  of  its  excessive  use  the  sugar  disap- 
pears from  the  urine. 

Illustrative  Cases. — In  a  series  of  observations  made  several 
years  ago  at  the  Country  Branch  of  the  New  York  Infant  Asylum, 
ten  children  were  selected  for  high-sugar  feeding,  10  percent  sugar 
mixtures  being  given  to  those  under  one  year  of  age.  Every 
case  showed  glycosuria  after  twenty-four  hours  of  the  high-sugar 
administration. 

Two  most  interesting  cases  of  persistent  glycosuria  without 
any  other  manifestation  of  illness  have  been  under  my  observa- 
tion for  the  past  six  years.  That  sugar  existed  in  the  urine  was 
discovered  by  accident.  How  long  it  may  have  been  present,  we 
have  no  means  of  knowing.  The  mother,  an  unusuallv  careful 
woman,  conceived  the  idea  that  it  would  be  wise  to  have  the 
urine  of  all  her  four  children  examined.  It  was  accordingly  sent 
to  me,  and  greatly  to  my  surprise  I  found  that  two  specimens, 
one  from  a  boy  of  four  years,  the  other  from  his  brother  of  six,  con- 
tained a  large  amount  of  sugar— 3  and  3.5  percent  respectively.  A 
careful  examination  was  at  once  made  of  both  patients,  and  nothing 
abnormal  discovered.  The  children  were  strong,  there  was  no 
unusual  thirst  and  no  polyuria,  and,  further,  the  examination 
of  the  urine  failed  to  reveal  the  presence  of  either  acetone  or 
diacetic  acid.     They  were  placed  on  a  rigid  anti-diabetic  diet  (page 


350 


THE    URINE 


351),  which  reduced  the  sugar  to  1.5  and  2  percent  respectively. 
During  the  six  years  that  have  since  intervened,  the  boys  have  made 
satisfactory  physical  and  mental  progress ;  they  have  attended  school 
regularly  except  when  prevented  by  the  usual  ailments  of  childhood. 
Both  have  undergone  operation  for  adenoids  and  enlarged  tonsils 
under  ether  anesthesia,  with  no  more  than  the  usual  discomfort. 
They  have  made  normal  increase  in  stature,  weight,  and  strength, 
and  are  perfectly  normal  in  appearance.  During  these  years  monthly 
examinations  have  been  made  of  the  urine.  There  has  never  been 
less  than  1.5  percent  of  sugar  in  either,  and  during  the  past  eighteen 
months  it  has  rarely  been  below  3  percent  or  above  6  percent,  and 
that  in  spite  of  the  most  careful  diet.  There  never  has  been  polyuria 
or  extreme  thirst.  The  children  have  been  seen  by  several  consult- 
ants in  New  York  city  and  have  been  under  the  treatment  of 
three  well-known  specialists  in  Germany.  Recently  acetone  has 
been  found  in  the  urine  of  one  of  the  children.  Probably  every  va- 
riety of  treatment  which  might  be  expected  to  exert  an  influence  on 
the  sugar  production  has  been  tried  for  protracted  periods  without 
a  particle  of  influence  in  reducing  it.  Indiscretions  in  diet  increase 
the  sugar,  otherwise  it  ranges  as  stated  above.  None  of  the  physi- 
cians here  or  abroad  who  have  treated  the  boys  has  seen  similar  cases. 
They  are  cited  in  detail  and  are  of  much  interest  as  showing  the  in- 
efificiency  of  medication  in  glycosuria  and  the  effects  of  diet,  and, 
furthermore,  they  present  a  clinical  picture  which  is  most  unusual. 
It  has  been  suggested  that  the  glycosuria  may  be  due  to  some 
persistent  and  unusual  toxemia  from  intestinal  sources,  and  the 
cases  are  now  being  studied  on  that  theory. 

DIABETES  INSIPIDUS— POLYURIA 
Persistent  polyuria — diabetes  insipidus — is  rare  in  children.  I 
have  personally  known  of  but  one  case.  It  had  been  but  little  influ- 
enced by  six  weeks'  treatment  at  the  time  it  passed  from  under  obser- 
vation. Temporary  or  transient  polyuria  is  of  occasional  occurrence 
and  appears  to  be  entirely  of  nervous  origin.  It  is  usually  seen  in 
nervous  girls  of  hysterical  tendencies.  It  is  most  apt  to  develop  at 
the  close  of  the  school  year,  when  a  child  is  considerably  reduced  or 
somewhat  excited  in  anticipation  of  undergoing  examinations.  The 
patient  is  thirsty,  drinks  quantities  of  fluid,  and  passes  a  great  deal 
of  pale  urine  of  low  specific  gravity.  Full  doses  of  bromid  of  soda — 
ten  grains  three  times  daily — may  temporarily  reHeve  these  condi- 
tions. In  all  the  cases  which  I  have  seen,  the  polyuria  ceased  in  a 
short  time,  with  the  cessation  of  school  duties  and  a  change  of  en- 
vironment. 

DIABETES  MELLITUS 
But  little  of  promise  is  to  be  offered  in  the  management  of  diabetes 
mellitus  in  children.     It  is  a  particularly  fatal  disease.     I  have  treated 


VESICAL    CALCULUS.       CYSTITIS  35I 

five  cases,  and  all  have  terminated  fatally.  This  is  similar  to  the 
experience  of  all  observers.  The  youngest  patient  was  three,  the 
oldest  nine  years  of  age.  The  manifestations  of  the  disease  were  the 
same  in  all.  There  were  excessive  thirst,  rapid  loss  in  weight,  the 
passage  of  large  quantities  of  urine  containing  varying  amounts  of 
sugar,  and  a  dry,  roughened  skin.  Not  one  of  my  patients  lived  a 
year  after  the  commencement  of  the  disease.  Death  usually  takes 
place  in  less  than  six  months. 

The  patients  were  treated  by  limiting  the  amount  of  fluid  taken, 
by  restricting  the  diet,  and  by  using  the  opium  derivatives  and 
arsenic  to  the  point  of  physiologic  effect — all  without  the  slightest 
benefit.  The  sugar  output  was  reduced,  but  the  patients  showed 
not  even  temporary  improvement  as  to  their  general  condition. 
Children  with  diabetes  mellitus  usually  die  from  exhaustion  or  from 
some  intercurrent  disease  like  pneumonia.  Uremia  is  of  less  frequent 
occurrence  in  children  than  in  adults. 

Diet. — The  following  are  permissible  articles  of  diet  for  a  child  ill 
with  diabetes :  Soup  and  broths  made  from  meat,  fresh  and  salt  fish, 
shell-fish  occasionally,  egg,  fowl,  and  game,  smoked  meats,  sweet- 
bread, cheese,  spinach,  celery,  lettuce,  cucumbers,  cranberries, 
radishes,  string  beans,  asparagus,  squash,  cabbage,  egg-plant,  to- 
matoes, onions,  turnips,  mushrooms,  gelatin  jellies  sweetened  with 
saccharin,  butter,  cream,  olive  oil,  cod-liver  oil,  lemon,  grape-fruit, 
sour  apples,  blackberries,  raspberries,  watermelon.  Nuts  of  all  kinds 
may  be  eaten.  Only  bread  and  biscuits  made  from  gluten  flour  should 
be  used.  It  is  impossible  to  procure  a  starch-free  gluten  flour ;  the 
flour,  however,  should  not  contain  more  than  20  percent  of  starch. 

VESICAL  CALCULUS-STONE  IN  THE  BLADDER 
Stone  in  the  bladder  is  rarely  seen  in  children  under  ten  years  of 
age.     Two  cases  only  have  come  under  my  obser\^ation.     The  pa- 
tients were  boys  aged  respectively  five  and  seven  years.     The  treat- 
ment of  the  condition  is  entirely  surgical. 

CYSTITIS 

Cystitis  is  an  uncommon  affection  in  children  and  I  have  never 
seen  a  case  in  a  boy.  In  girls,  however,  it  is  of  occasional  occurrence, 
and  is  usually  due  to  an  infection  of  the  bladder  with  the  colon  bacillus. 
There  is  little  or  no  pain  attending  urination,  but  there  are 
frequent  calls  to  urination,  of  the  most  urgent  character.  All  of  my 
cases  of  cystitis  have  suffered  from  incontinence  of  urine,  during  both 
waking  and  sleeping  hours.  We  are  sometimes  told  by  the  mother 
that  the  child  asked  to  be  taken  to  the  toilet,  but  passed  the  urine 
before  reaching  it.  Inability  voluntarily  to  control  the  urine  during 
the  day,  extending  over  a  considerable  period  of  time,  points  strongly 
to  bladder  involvement,  either  to  stone,  which  is  exceedingly  rare  in 


352 


THE   URINE 


children,  or  to  cystitis.     An  examination  of  the  urine  usually  clears 
up  the  diagnosis  so  far  as  the  cystitis  is  concerned. 

Treatment. — The  treatment  is  largely  through  internal  medication, 
and  is  not  particularly  promising  as  regards  the  promptness  of  a  cure. 
Irrigation  of  the  bladder  may  be  attempted.  It  has  been  of  very  little 
service  in  my  hands.  Bladder-washing  is  carried  on  with  no  httle 
difficulty  and  annoyance  and  usually  with  unsatisfactory  results. 
My  best  success  has  been  by  the  use  of  urotropin — three  grains,  three 
times  daily  to  a  child  three  years  of  age.  In  cases  due  to  the  colon 
bacillus  it  is  well  to  alternate  the  urotropin  with  citrate  of  potash, 
three  grains  of  which  are  given  three  times  daily,  the  urotropin  being 
given  alone  for  five  days,  followed  by  the  citrate  of  potash  for  the  same 
time,  alternating  thus,  when  necessary,  until  a  cure  is  effected. 

ACUTE  PYELITIS 

Pyelitis  is  a  rare  disease  in  children.  In  a  great  majority  of  the 
cases  the  disease  is  due  to  an  infection  of  the  pelvis  of  the  kidney  with 
the  colon  bacillus.  I  have  seen  but  four  cases  of  this  nature, 
all  in  girls  under  fifteen  months  of  age.  In  two  there  was  a  coli- 
cystitis ;  in  the  others,  the  colon  bacillus  was  found  in  pure  culture. 
Both  of  the  latter  were  recovering  from  enterocoHtis. 

The  only  symptoms  in  two  of  the  cases  were  repeated  severe 
chills — a  verv  unusual  occurrence  in  an  illness  in  an  infant — and  a 
high  temperature  w^ith  a  tendency  toward  wide  fluctuations.  The 
severe  chills,  the  temperature  range,  and  the  absence  of  other  clinical 
signs,  together  wdth  a  negative  blood  examination,  suggested  pyehtis. 
Examination  of  the  urine  revealed  the  colon  bacillus.  In  the  two 
other  cases  seen  in  consultation  there  was  an  irregular  temperature, 
ranging  from  ioo°  to  105°  F. ,  which  had  continued  for  several  days  and 
which  could  not  be  accounted  for.  The  urine  was  examined  bacteri- 
ologically  with  a  view  of  clearing  the  diagnosis,  which  resulted  in  the 
discovery  of  the  colon  bacillus.  The  patients  were  given  two  grains 
of  the  citrate  of  potash  every  two  hours— six  doses  being  given  daily. 
In  the  cystitis  cases  two  grains  of  urotropin  were  given  three  times 
daily  in  addition  to  the  citrate  of  potash.    All  made  prompt  recoveries. 

THE  MALE  GENITALS 

Practically  every  male  child  is  born  with  an  adherent  prepuce 
and  with  more  or  less  constriction  at  the  preputial  outlet.  The 
penis  is  to  be  considered  normal  only  when  the  foreskin  can  easily 
be  retracted,  laying  bare  the  glans. 

The  adhesions  and  constrictions  may  be  relieved  by  moderately 
stretching  the  foreskin  and  breaking  up  the  adhesions  with  a  fine 
blunt  probe,  after  which  the  glans  should  be  cleansed,  oiled,  and  the 
foreskin  drawn  forward  over  it.  The  cleansing  of  the  parts  with 
castile  soap  and  warm  water,  which  necessitates  a  retraction  of  the 


PHIMOSIS.       PARAPHIMOSIS  353 

foreskin,  should  be  practised  at  least  every  second  day.  This  not  only 
keeps  the  parts  clean,  but  prevents  the  later  formation  of  adhesions 
and  a  possible  phimosis. 

Hypospadias  and  epispadias  are  conditions  essentially  surgical, 
and  therefore  are  not  considered  here. 

PHIMOSIS 

Phimosis  is  a  condition  caused  by  a  constriction  or  narrowing  of 
the  preputial  orifice,  sometimes  to  a  pin-point.  In  cases  where  the 
foreskin  is  tightly  bound  to  the  glans  by  adhesions,  the  urine  may  be 
emitted  in  drops;  in  other  cases  the  prepuce  "balloons  out"  during 
urination  and  the  urine  dribbles  away.  The  opening  may  be 
sufficiently  large  to  show  under  pressure  the  margin  of  the  urethral 
opening,  and  urination  will  be  but  little  interfered  with. 

Treatment. — The  cases  in  which  urination  is  impeded  require 
prompt  relief.  This  can  be  furnished  temporarily  by  introducing  a 
small  probe  or  a  director  and  carefully  slitting  the  skin  with  sharp- 
pointed  scissors  until  the  glans  is  reached.  The  child  should  be 
carefully  held  by  an  attendant  during  the  operation  and  great  care  ex- 
ercised in  introducing  the  director.  After  the  operation  a  wet  dress- 
ing of  bichlorid  of  mercury,  i  :  6000,  or  a  saturated  solution  of  boric 
acid  should  be  applied  to  the  wound  until  healed. 

A  few  years  ago  I  saw  a  case  in  which  the  probe  had  been  intro- 
duced into  the  urethra  and  followed  up  by  the  scissors,  which  had 
made  a  slit  involving  one-third  of  the  glans. 

Phimosis  may  be  productive  of  various  nervous  manifestations, 
such  as  restlessness  and  irritability.  In  two  of  my  cases  convulsions 
were  apparently  caused  by  phimosis.  Both  children  had  repeated 
convulsions  until  they  were  circumcised.  Both  suffered  from  marked 
phimosis  with  retained  smegma  and  irritation  of  the  prepuce. 

Circumcision  should  never  be  delayed  in  cases  of  phimosis,  as  it 
furnishes  the  only  satisfactory  means  of  relief.  Stretching  is  very 
apt  to  be  followed  by  re-contraction,  which  only  intensifies  the  origi- 
nal condition,  while  the  unavoidable  laceration  of  the  mucous  mem- 
brane may  open  a  favorable  field  for  infection.  In  hospitals  and  out- 
patient work,  examples  are  numerous  of  the  harm  resulting  from 
force  and  lack  of  cleanliness  in  the  management  of  these  simple  and 
easily  remedied  conditions. 

PARAPHIMOSIS 
Paraphimosis  is  produced  by  the  retraction  of  a  tight  foreskin, 
which  later  becomes  so  contracted  behind  the  corona  as  to  prevent 
the  return  venous  flow.  As  a  result,  the  glans  become  greatly  swol- 
len, deeply  congested,  and  edematous.  Urination  is  impossible. 
The  cases  which  I  have  seen  have  all  been  produced  by  the  mother 
or  nurse  in  an  attempt  to  retract  a  tight  foreskin  according  to 
23 


354  THE    MALE    GENITALS 

the   doctor's  directions,    after  he    had    stretched   the    prepuce   for 
phimosis. 

Treatment. — If  the  retracted  skin  is  edematous,  it  may  be  punc- 
tured in  various  places  to  let  out  the  fluid.  Reduction  may  then  be 
attempted  by  taking  the  glans  between  the  thumb  and  the  first  and 
second  fingers  of  the  right  hand  and  making  gradual  pressure  back- 
ward against  the  thumb  and  first  finger  of  the  left  hand,  which  grasps 
the  penis  behind  the  prepuce.  If  the  reduction  cannot  be  effected  in 
this  way,  as  occasionally  happens,  if  the  case  is  of  long  standing  or  the 
contraction  very  tight,  a  longitudinal  dorsal  incision  may  be  made  in 
the  skin  at  the  site  of  the  constriction.  After  the  reduction  a  wet 
dressing  of  a  saturated  solution  of  boric  acid  or  of  bichlorid  of  mer- 
cury, 1 :  10,000,  should  be  kept  constantly  applied  to  the  parts  until 
the  swelling  has  subsided,  when  circumcision  should  be  done. 

BALANITIS 

Balanitis  is  a  swelling  and  inflammation  of  the  foreskin  due  to  a 
local  infection.  Unskilled  manipulation  in  stretching  the  prepuce 
readily  produces  a  laceration,  opening  up  a  means  of  entrance  for  bac- 
teria. In  severe  cases  the  parts  first  show  congestion  and  then  edema. 
I  have  seen  patients  with  long  foreskins  which  were  twisted  and 
swollen  to  a  size  three  or  four  times  that  of  the  penis.  In  advanced 
cases  there  will  be  suppuration  beneath  the  foreskin  with  a  purulent 
discharge  from  the  orifice. 

Treatment. — If  the  case  is  seen  early,  a  wet  dressing  made  by 
wrapping  the  parts  in  gauze  or  old  linen,  which  is  saturated  with  an 
ice-cold  solution  of  bichlorid  of  mercury  i :  10,000  and  changed  every 
half  hour,  will  usually  be  effective.  If  there  is  much  edema,  punc- 
turing in  several  places,  after  disinfection,  should  precede  the  wet 
dressing.  If  there  is  a  purulent  discharge,  the  sac  should  be  gently 
syringed  at  least  twice  daily  with  a  3  percent  solution  of  hydrogen 
peroxid,  diluted  one-half  with  water. 

When  the  suppuration  has  ceased,  with  a  return  to  normal  of 
the  parts  involved,  circumcision  should  be  done.  Operation  during 
the  acute  stage,  particularly  with  suppuration  present,  should  be 
avoided  unless  the  condition  is  very  urgent. 

CIRCUMCISION 

Many  times  during  the  year  I  am  asked  the  question,  "Shall  we 
have  the  baby  circumcised?"  My  answer  as  to  the  advisability  of 
this  operation,  as  a  routine  measure,  is  in  the  affirmative.  The  oper- 
ation during  the  second  week  of  life  is  a  trivial  matter.  I  am  con- 
vinced that  it  would  be  for  the  best  interest  of  every  male  if  he  were 
circumcised.  In  one  out  of  every  five  male  infants  circumcision  is  a 
necessitv  both  for  his  comfort  and  his  health.  In  marked  degrees  of 
phimosis  and  balanitis,  circumcision  is  the  only  means  of  relief. 

An  important  reason,  to  my  mind,  for  the  operation  as  a  routine 


ORCHITIS  355 

measure,  is  that  it  settles  at  once  and  for  all  time  the  toilet  of  the  parts. 
The  penis  after  a  proper  circumcision  requires  no  further  manipulation 
on  the  part  of  the  nurse.  The  daily  retraction  of  the  foreskin  and  bath- 
ing of  the  parts  is  one  of  the  best  means  of  teaching  the  child  self- 
abuse.  When  this  is  not  done  every  day  or  at  least  every  second 
day,  trouble  is  sure  to  follow  sooner  or  later,  in  the  form  of  adhesions 
and  inflammation  of  the  prepuce.  The  sensations  produced  by  the 
retraction  and  the  washing  are  not  unpleasant  and  the  child  soon 
learns  to  produce  them  himself,  through  leg  rubbing,  hand  pressure, 
or  otherwise.  (See  Masturbation,  page  433.)  Time  and  again,  after 
having  stretched  the  foreskin  and  broken  up  the  adhesions,  operations 
having  been  refused,  I  have  had  the  case  return  in  a  few  weeks  with 
the  adhesions  and  the  contractions  as  bad  as  before,  the  nurse  or 
mother,  timid  or  neglectful,  having  failed  to  follow  my  directions. 
With  phimosis  it  may  require  considerable  skill  to  draw  the  foreskin 
forward  after  a  retraction.  It  is  not  always  safe  to  permit  the 
attendants  to  attempt  it.  Not  a  few  times  I  have  seen  a  paraphi- 
mosis (page  353)  which  resulted  from  an  inabiHty  to  bring  forward  a 
retracted  tight  foreskin. 

The  dorsal  sht,  so  often  practised  as  a  substitute  for  circumcision, 
is  to  be  used  only  as  a  temporary  expedient,  and  as  such  maybe  em- 
ployed whenever  circumcision  is  refused.  Never,  by  any  means,  does 
it  take  the  place  of  circumcision.  It  inyariablv  leaves  a  long,  redun- 
dant flap  of  skin,  which  easily  becomes  irritated,  causing  no  little 
discomfort.  For  the  child,  it  also  is  a  great  temptation  to  mani- 
pulation. 

GONORRHEA  IN  THE  MALE 

Specific  urethritis  in  male  infants  and  "runabout"  male  children 
is  a  condition  seen  but  rarely,  only  one  case  having  come  under  my 
observation.  This  was  in  a  four-year-old  boy  whose  home  was  in  a 
small  tenement  and  who  had  been  repeatedly  exposed  through  an- 
other member  of  the  family,  who,  having  imbibed  the  fallacy  popular 
among  the  ignorant,  hoped  to  rid  herself  of  the  trouble  by  giving  it  to 
the  boy! 

The  treatment  in  this  case  was  with  irrigation  of  the  urethra  with 
a  1 :  10,000  solution  of  the  permanganate  of  potash.  The  irrigation 
was  used  at  twelve-hour  intervals  for  two  weeks.  After  four  weeks' 
treatment  the  boy  passed  from  under  my  care,  having  been  placed  in  an 
institution.  During  the  last  two  weeks  of  the  treatment  the  irrigations 
were  used  once  daily.   There  was  no  further  trouble  from  the  urethritis. 

ORCHITIS 

Swelling  of  the  testicles  is  of  very  infrequent  occurrence  in  the 
young.  I  have  seen  but  three  cases — two  complicating  mumps,  the 
other  occurring  with  an  earlv  gonorrhea. 

The  management  is  rest  in  bed,  saline  laxatives,  if  necessary,  and 
support  of  the  inflamed  testicles  by  a  wide  strip  of  adhesive  plaster 


356  THE    MALE    GENITALS 

extending  from  thigh  to  thigh.  The  appHcation  of  warm  sedative 
lotions  gives  much  rehef  to  the  pain  and  discomfort  and  appears  to 
shorten  the  duration  of  the  attack.  Lead  and  opium  solution,  U.  S. 
P.,  applied  on  several  layers  of  gauze  and  covered  with  cotton- wool, 
was  a  satisfactory  treatment  in  cases  complicating  mumps.  The 
dressing  should  be  repeated  every  three  hours.  The  gonorrheal  case 
also  responded  to  this  treatment,  but  required  a  much  longer  time 
for  resolution  to  take  place.  After  an  orchitis  a  suspensory  ban- 
dage should  be  worn  for  several  months. 

HYDROCELE 

Hydrocele  in  the  different  forms  in  infants  under  one  year  of  age 
is  frequently  seen  in  children's  institutions  and  in  out-patient  clinics 
for  children.  Not  a  few  of  these  cases  have  been  under  treatment 
elsewhere.  Drugs,  such  as  the  iodid  of  potash,  have  been  given  with 
an  idea  of  absorbing  the  fluid — a  valueless  procedure.  Some  of  the 
cases  have  been  aspirated,  and  to  others  local  counter-irritants  have 
been  applied.  If  there  is  a  very  large  and  encysted  hydrocele,  and 
if  the  parents  are  anxious  for  a  speedy  cure,  aspiration  with  a  hypo- 
dermic syringe  may  be  done,  remembering,  of  course,  that  the  opera- 
tion must  be  aseptic  in  every  detail. 

In  a  recent  case  which  came  to  the  out-patient  service  of  the 
New  York  Polyclinic  there  h^-d  been  an  aspiration  performed.  The 
sac  became  septic  and  the  child  died  from  the  infection. 

Not  more  than  one-eighth  of  the  fluid  need  be  withdrawn. 
After  the  withdrawal  of  the  needle,  the  site  of  the  puncture 
should  be  dressed  with  collodion  and  aristol,  one-half  dram  of 
aristol  to  one-half  ounce  of  collodion.  I  have  never  found  it  nec- 
essary to  inject  into  the  sac  any  form  of  irritant,  such  as  carbolic 
acid  or  iodin.  In  fact,  fully  98  percent  of  the  cases  get  well  just  as 
quickly  without  treatment.  If  the  hydrocele  is  a  small  one,  our 
management  at  the  present  time  is  to  let  it  alone,  and  spontaneous 
recovery  follows  in  from  two  to  three  months. 

UNDESCENDED  TESTICLE 

In  the  normal  male  at  birth  both  testicles  should  be  in  the  scro- 
tum. In  a  considerable  number  of  cases  one  or  both  testicles  may 
remain  in  the  canal  for  a  varying  period,  the  descent  usually  taking 
place  during  the  first  year.  When  such  descent  does  not  occur,  the 
condition  may  be  considered  abnormal.  It  is  important  not  to  mis- 
take the  condition  for  hernia  and  apply  a  truss.  Not  a  little  harm 
may  result  from  such  an  error. 

A  truss  should  never  be  used  in  such  a  case  and  operative  pro- 
cedures should  be  delayed  until  puberty,  unless  discomfort  is  ex- 
perienced or  disease  can  be  proved.  I  have  known  many  cases  in 
which  descent  did  not  take  place  until  the  third  or  fourth  year.  In 
one  case  it  was  as  late  as  the  tenth  vear. 


THE   FEMALE   GENITALS 

SIMPLE  VULVOVAGINITIS 

In  simple  vulvovaginitis  there  is  an  inflammation  of  the  external 
genitals  with  a  secretion  of  rather  viscid  mucus.  There  is  moderate 
itching  and  a  burning  sensation  about  the  parts — symptoms  which 
may  resemble  those  of  gonorrheal  infection.  The  cases  in  which 
there  is  a  purulent  discharge  are  particularly  apt  to  be  mistaken  for 
gonorrhea.  Bacteriologic  examination  in  such  cases  is  the  only 
immediate  means  of  differentiating  the  two  diseases. 

Ill-conditioned  children  and  those  improperly  cared  for  furnish 
the  majority  of  the  vulvovaginitis  patients.  The  disorder  is  to  be 
regarded  as  one  due  to  a  low  vitaUty  rather  than  to  a  local  infection. 

Treatment. — Accordingly  the  management  is  largely  constitu- 
tional: Outdoor  life,  suitable  food,  iron  and  cod-liver  oil,  are  to  be  ad- 
vised, and,  in  short,  all  the  measures  advocated  in  the  section  on  Deli- 
cate Children  are  apphcable  here.  Bathing  the  genitals  twice  a  day 
with  warm  water  and  castile  soap,  followed  by  drying  with  absorbent 
cotton,  prepares  the  parts  for  a  dusting-powder  which  I  have  found 
useful  in  these  cases.     The  powder  used  is  of  the  following  composition : 

I^.     Acidi  borici gr.  xxv 

Pulveris  amyli 

Pulveris  zinci  oxidi aa   oss 

The  dryer  the  inflamed  surfaces  are  kept,  the  more  prompt  will  be 
the  relief,  so  that  if  there  is  a  tendency  to  a  free  secretion  of  mucus, 
the  powder  may  be  applied  at  intervals  of  two  hours. 

A  convenient  means  of  applying  the  powder  is  w4th  an  insuffla- 
tor, which  may  be  obtained  from  any  apothecary.  After  the  parts 
are  packed  with  the  powder,  a  dressing  of  old  linen  should  be  applied 
and  held  in  position  by  a  napkin  binder.  The  powder  should  be  re- 
appHed  often  enough  to  keep  the  parts  dry. 

GONORRHEAL  VULVOVAGINITIS 

The  disease  is  seen  with  great  frequency  in  out-patient  work. 
The  specific  infection  is  usually  furnished  by  some  member  of  the 
family  or  by  some  other  infected  child.  It  is  readily  transmitted  by 
sponges,  towels,  napkins,  etc. 

In  a  typical  case  there  is  a  profuse,  greenish-yellow  discharge. 
The  parts  may  be  swollen  and  edematous.  The  course  of  the  disease 
is  most  protracted  and  there  is  no  specific  medication  which  we  can 
use  locally  or  otherwise. 

Treatment. — It  seems  to  me,  after  treating  in  many  different 
ways  several  hundred  of  these  cases,  that  keeping  the  parts  clean 
through  douching  does  more  toward  terminating  the  disease  than 
does  the  use   of  any  particular  disinfectant  wash  or  application. 

357 


358  THE   FEMALE   GENITALS 

Douching  of  the  parts  is  to  be  practised  four  times  daily,  if  possible, 
two  quarts  of  water  being  used.  It  is  useless  to  attempt  the  treat- 
ment of  a  case  which  cannot  be  douched  at  least  twice  a  day.  It  may 
be  remarked  that  it  is  a  very  trying  treatment  for  both  patient  and 
nurse.  Such  is  certainly  the  case,  but  we  are  dealing  with  a  disease 
in  which  strenuous  measures  only  give  hope  of  cure.  In  order  to  use 
the  douche  most  effectively,  the  child  is  placed  on  its  back  on  a 
douche-pan.  A  glass,  female  catheter  attached  to  a  fountain  syringe 
is  all  the  apparatus  required.  The  catheter  is  passed  about  one-half 
inch  within  the  vaginal  orifice  and  the  water  allowed  to  run.  The 
lower  end  of  the  bag  should  not  hang  higher  than  two  feet  above  the 
child's  body.  Boric  acid  is  a  safe  drug  in  any  household.  For  this 
reason  it  is  selected  instead  of  bichlorid  of  mercury,  permanganate 
of  potash  or  any  other  antiseptic.  I  am  not  at  all  sure  that  plain 
boiled  water  would  not  answer  just  as  well.  It  would  be  difficult, 
however,  to  persuade  many  families  to  use  the  repeated  douching 
without  the  addition  of  some  antiseptic  to  the  water.  Accordingly, 
the  mother  or  nurse  is  instructed  how  to  prepare  two  quarts  of  a 
saturated  solution  of  boric  acid.  This  is  used  as  a  cleansing  agent. 
After  the  parts  are  dried  with  sterile  absorbent  cotton,  a  dusting- 
powder,  the  formula  of  which  is  as  follows,  is  used  very  freely: 

I^.     Acidi  borici gr.  xxv 

Pulveris  amyli 

Pulveris  zinci  oxidi aa   oss 

The  powder  is  freely  dusted  into  the  vagina  and  over  the  diseased 
surface  after  the  douche,  and  at  two-hour  intervals,  during  the  time 
the  child  is  awake,  from  early  morning  to  late  at  night.  I  tell  the 
attendants  to  pack  the  parts  with  the  powder.  Over  this  is  placed 
absorbent  cotton  or  gauze,  which  is  covered  with  the  napkin.  The 
attendants  should  be  warned  of  the  danger  of  infecting  themselves 
and  other  children  in  the  household  with  towels,  sponges,  etc. ;  in 
fact,  sponges  should  never  be  used  in  these  cases.  The  danger  of 
infecting  the  eyes,  not  only  of  the  patient  but  of  the  attendants  and 
others  who  may  come  in  contact  with  the  case,  should  be  carefully 
explained.  When  washing  or  drying  is  necessary  absorbent  cotton 
or  old  linen  should  be  used  and  immediately  burned.  A  child  suf- 
fering from  gonorrheal  vaginitis  should  sleep  alone.  Cheese-cloth 
napkins  should  be  used  and  burned  as  soon  as  soiled. 

A  case  treated  as  above  may  recover  in  three  weeks,  though  usu- 
ally from  four  to  eight  weeks  are  required,  and  in  some  cases  the  treat- 
ment must  be  continued  for  months.  After  we  have  arrived  at  a 
point  where  we  consider  the  case  cured,  there  will  sometimes  be  a 
renewal  of  the  discharge  and  the  treatment  must  be  resumed. 

Before  the  case  is  finally  discharged  at  least  two  bacteriologic 
examinations  of  the  vaginal  secretion  should  be  made  in  order  to 
determine  positively  the  absence  of  the  gonococcus. 


NERVOUS  DISORDERS 

HEADACHE 

A  complaint  of  headache  on  the  part  of  a  child  should  always  re- 
ceive attention.  It  is  unusual  in  children,  and  when  it  is  repeatedly 
noted  there  is  generally  a  good  reason  for  it. 

In  children  of  any  age  headache  may  be  an  early  symptom  of 
meningitis,  particularly  of  the  tuberculous  form,  in  which  the  head- 
ache may  exist  for  days  without  other  signs  of  illness.  In  eye-strain, 
headache  is  a  very  prominent  symptom,  and  may  be  the  only  evi- 
dence that  an  ocular  defect  exists.  In  persistent  headache  that 
cannot  otherwise  be  satisfactorily  explained  I  invariably  have  the 
eyes  examined.  Headache  is  often  the  earliest  sign  of  acute  infec- 
tious disease,  it  being  usually  a  premonitory  symptom  of  scarlet 
fever,  measles,  or  pneumonia.  Persistent  toxemia  from  any  source 
may  be  a  cause  of  headache.  It  may  occur  in  nephritis  and  in 
malaria.  The  most  usual  toxic  source,  however,  is  the  intestinal 
tract,  in  which  there  is  generally  the  association  of  anemia  as  well. 
This  condition  may  exist  without  constipation.  Fatigue,  as  a  result 
of  overwork  at  school,  or  hard  play  and  unusual  excitement  may  be 
a  cause  of  headache  in  neurotic  children.  It  is  frequently  encoun- 
tered in  girls  late  in  the  school-year.  Examination  of  the  urine 
may  show  marked  indicanuria.  In  three  cases  recently  seen  by  me, 
headache  was  the  only  evidence  of  intestinal  derangement. 

Treatment.— The  management  of  headache  consists  in  the  dis- 
covery and  removal  of  the  cause.  An  ice-bag  or  an  ice-cloth  applied 
to  the  head  affords  much  relief  in  the  acute  febrile  cases.  Ocular 
defects  should  have  the  benefit  of  rest  and  suitable  glasses  prescribed 
by  an  oculist.  Fatigue  headaches  are  best  controlled  by  limiting  the 
amount  of  work  and  providing  long  periods  of  rest.  Headaches  due 
to  intestinal  toxemia  with  the  usual  accompaniment  of  anemia  are 
oftentimes  most  difficult  to  relieve.  In  spite  of  our  best  efforts  the 
intestinal  digestion  may  remain  faulty  for  a  considerable  time.  A 
change  of  residence  and  a  radical  change  in  the  habits  of  life  are 
usually  the  best  means  of  effecting  a  cure.  The  management  of 
these  cases  is  considered  in  detail  under  Persistent  Intestinal  Indi- 
gestion (page  162). 

HYSTERIA 
Hysteria  in  children  is  rarely  seen  before  the  third  year.     My 
youngest  case  was  three  and  one-half  years  of  age  when  first  seen  by 

359 


360  NERVOUS   DISORDERS 

me,  but  the  hysterical  manifestations  had  been  present  for  several 
months.  Mental,  motor,  or  sensory  manifestations  may  predominate 
in  an  individual  case,  although  all  cases  are  associated  more  or  less 
directly  with  an  absence  of  mental  control.  Girls  are  much  more 
frequently  affected  than  boys,  but  some  of  the  most  typical  cases 
coming  under  my  observation  have  been  among  the  latter. 

We  are  taught  by  neurologists  that  hysteria  is  almost  invariably 
of  hereditary  origin  because  of  its  apparent  direct  transmission  from 
parent  to  child.  It  must  be  remembered  that  the  child,  in  addition 
to  being  born  of  an  hysterical  mother,  is  thereafter  in  constant  asso- 
ciation with  her.  To  my  mind,  in  hysteria  we  have  exemplified  in  the 
most  perfect  degree  the  effect  of  environment.  A  neurotic  hysterical 
mother  puts  the  whole  family  in  a  state  of  high  nervous  tension.  I 
know  of  several  such  instances.  A  neurotic  irritable  father  will 
make  the  whole  family  neurotic.  I  know  of  such  instances  also. 
Fortunately  for  the  offspring,  both  conditions  are  seldom  combined 
in  one  family.  When  they  are,  and  I  have  the  children  of  a  few  such 
families  under  my  care,  the  future  of  the  children  is  discouraging. 
When  one  of  the  parents  is  sufficiently  normal  to  offset  a  reasonable 
degree  of  neurosis  on  the  part  of  the  other,  a  stable  equilibrium  may 
be  maintained. 

Imitation  is  one  of  the  strongest  characteristics  of  the  growing 
child.  How  often,  when  arranging  with  the  mother  a  diet-list  for 
one  of  these  nervous,  ill-conditioned  children,  have  I  heard  the 
child  say  that  he  "hated"  cereals,  or  "hated"  vegetables,  or 
"hated"  eggs  or  fowl;  or  that  he  "adored"  some  other  article  of 
food,  this  adoration  and  hatred,  particularly  the  latter,  often  influ- 
encing the  entire  future  of  the  child;  for  without  a  properly  regu- 
lated diet  for  every  day  in  the  year,  only  an  inferior  type  of  adult  can 
be  the  outcome.  In  such  cases  it  will  usually  be  found  that  the  likes 
and  dislikes  of  the  child  are  identical  with  those  of  the  parents,  whose 
preference  had  often  been  expressed  in  the  presence  of  the  child. 
"Hereditv"  here  furnishes  to  the  parents  a  satisfactory  explanation 
of  the  child's  limitations  in  diet.  It  will  usually  be  found  that 
parents  who  live  normally  have  children  who  eat  normally. 

Illnesses  and  ailments  of  different  kinds  should  not  be  discussed 
before  nervous  and  impressionable  children.  Time  and  again  an  in- 
vestigation of  a  peculiar  pain  in  a  child's  head,  side,  or  back  which 
cannot  be  accounted  for  by  the  physical  examination  will  be  ex- 
plained bv  a  similar  pain  in  some  older  member  of  the  family. 

Illustrative  Cases. — In  one  family  I  have  seen  three  generations 
of  genuine  hysteria.  In  the  first  generation  were  the  father  and 
mother.  The  father,  chronically  irritable  and  neurotic,  was  a  busi- 
ness man  with  large  interests,  rarely  ceasing,  when  at  home,  to  talk 
about  his  ailments  and  their  remedies.  The  mother  had  marked 
hysteria.     She  indulged  in  frequent  attacks,  with  apparent  uncon- 


HYSTERIA  361 

sciousness  lasting  for  hours.  The  daughter,  brought  up  in  this 
atmosphere,  through  heredity  and  environment  soon  became 
markedly  hysterical.  Both  she  and  the  mother,  when  some  dispute 
arose  in  the  family,  which  was  not  an  infrequent  occurrence,  would 
have  simultaneous  attacks  of  hysteria.  In  due  time  the  daughter 
married  and  gave  birth  to  a  daughter  who  promises  to  maintain  the 
familv  traditions  with  certain  additions  of  her  own. 

I  have  under  my  care  a  girl  seven  years  of  age  who  is  in  deadly 
fear  of  appendicitis  and  develops  an  attack  of  hysteria  every  time  she 
has  a  pain.  She  can  locate  "McBurney's  point"  and  knows  the 
various  stages  in  the  development  of  the  disease  and  the  steps  in  the 
operation  for  appendicitis.  The  mother's  appendix,  suitably  pre- 
served, is  among  the  family  relics,  whence  it  cannot  be  removed. 
The  influence  of  heredity  has  perhaps  had  the  effect  of  making  the 
child  alert,  precocious,  and  impressionable,  and  such  favorable  soil 
and  the  constant  association  with  the  hysterical  will  almost  surely 
develop  hysteria  in  a  child. 

Treatment. — General.— My  results  with  hysterical  children  have 
usually  been  very  good  or  very  poor,  depending  to  a  great  extent 
upon  my  ability  to  separate  the  child  from  its  family,  by  this  state- 
ment the  management  of  hysterical  children  is  suggested.  Re- 
move the  child,  if  possible,  from  the  unfavorable  family  influence. 
The  boarding-school  has  effectually  cured  several  of  my  cases.  Here 
the  child  is  placed  under  the  care  of  trained  minds,  teachers  who 
bring  out  the  good  and  correct  the  bad  by  reason,  precept,  and 
example,  and  who  thus  exert  a  continuous,  beneficial  influence.  In 
the  boarding-school,  plain  diet,  pleasant  occupation,  agreeable  asso- 
ciation, and  a  scientifically  regulated  life  replace  the  spoiUng  and 
coddUng  and  oftentimes  the  unsuitable  food,  together  with  the  end- 
less nagging  which  the  neurotic  mother  is  very  apt  to  indulge  in, 
with  the  best  intentions,  of  course,  but  nevertheless  with  a  most 
unfortunate  effect  upon  the  child.  If  the  child  is  too  young  for  a 
boarding-school  or  if  admission  is  denied  him,  he  should  be  placed 
under  the  care  of  some  kindly,  well-balanced  woman  as  companion 
and  instructor,  and  see  as  little  of  his  family  as  possible,  otherwise 
but  little  can  be  expected  from  the  treatment.  Of  course,  the  con- 
ditions must  be  explained  fully  to  the  parents  in  order  that  they 
may  make  an  effort  in  the  right  direction  as  to  their  bearing  toward 
the  child.  If  the  former  conditions  as  to  intimate  association  with 
the  child  continue,  the  good  intentions,  according  to  my  observation, 
may  last  only  a  very  few  days.  It  is  impossible  to  reform  the  habits 
of  life  of  a  neurotic  adult.  If  he  has  grown  that  way,  that  way  he 
will  remain.  The  only  hope  for  the  child  is  in  his  complete  removal 
from  such  unfavorable  influences. 

The  further  treatment  of  hysterical  children  consists  in  curtail- 
ing  the   mental   and  physical    activities,   which   almost   invariably 


362  NERVOUS   DISORDERS 

have  been  excessive.  A  rational  scheme  of  Uving  should  be  formu- 
lated. "Showing  off"  the  child  to  visitors  and  others  should  be 
forbidden.  If  under  ten  years  of  age,  he  should  retire  at  seven 
o'clock  every  night  and  rise  at  seven  every  morning.  It  is  under- 
stood by  the  attendant  that  this  does  not  mean  6.45  or  7.15. 
Every  day  after  the  midday  feeding,  the  child  should  rest  quietly 
in  a  darkened  room  for  an  hour  or  two.  Whether  he  sleeps  or  not, 
he  rests  in  a  recumbent  position  with  clothing  removed.  For 
such  children  exciting  games  of  stress  and  competition  of  every 
nature  are  forbidden.  An  outdoor  life  is  encouraged.  A  bicycle,  a 
pony,  an  individual  play-room  in  winter  and  a  tent  on  the  lawn  in 
summer  should  be  provided  when  possible.  School  instruction  may 
be  given,  but  the  child  is  not  to  be  crowded.  The  amount  of  study 
and  work  depends,  of  course,  upon  the  child's  condition.  Until  the 
tenth  year,  however,  there  should  be  but  one  morning  session,  of 
from  one  and  one-half  to  three  hours.  The  child  is  given  a  tub-bath 
or  brine  bath  daily  at  90°  F.  (page  31);  at  the  completion  of  the 
bath  he  stands  w'ith  his  feet  in  warm  water  and  is  given  a  cool  douche, 
at  60°  to  70°  F.,  the  spray  tube  being  attached  to  a  faucet;  or  cold 
water  may  be  poured  down  the  spine.  The  application  of  cold  water 
should  be  for  a  few  seconds  only  and  should  be  followed  by  a  brisk 
rubbing  with  a  rough  towel,  which  should  result  in  a  decided  skin 
reaction. 

Treatment  During  Hysterical  Seizure. — During  a  hysterical  seiz- 
ure the  child  should  be  treated  with  kindness  but  with  firmness.  No 
sympathy  should  be  shown.  The  application  of  ice-water  to  the 
face  and  chest  is  usually  sufficient  to  break  up  an  attack.  In  some 
cases  a  certain  amount  of  time  appears  to  be  required  for  a  return  to 
the  normal. 

Drugs. — Sedative  drugs,  such  as  the  bromids,  should  not  be  used. 
Cases  have  come  under  my  observation  showing  the  bromid  rash. 
Such  treatment,  as  also  the  use  of  the  opium  derivatives,  cannot  be 
too  strongly  condemned.  Drugs  that  increase  the  appetite  and  im- 
prove nutrition  should  be  given.  I  have  found  that  iron  and  arsenic 
answer  well  in  these  cases,  as  most  of  the  patients  show  a  secondary 
anemia.  For  a  child  from  five  to  ten  years  of  age  the  following 
prescription  has  been  useful : 

I^.     Liquoris  potassii  arsenitis gtt.  xc 

Extract!  ferri  pomati gr.  x 

Quininae  bisulphatis gr.  Ix 

M.  div.  et  ft.  capsulee  No.  xxx. 

Sig. — Take  one  after  each  meal. 

If  constipation  results  from  the  use  of  the  small  doses  of  iron,  one- 
third  to  one-half  grain  of  the  extract  of  cascara  may  be  added  to  each 
capsule.  If  the  child  cannot  swallow  a  capsule  the  following  may  be 
used- 


INFANTILE    CONVULSIONS  363 

I\.     Liquoris  potassii  arsenilis gtt.  Ixxij 

Ferri  et  ammonise  citratis gr.  xxiv 

Elixiris  simplicis oss 

Aquae q.  s.  ad   5iv 

M. 

Sig. — One  teaspoonful  after  each  meal  in  a  glass  of  water. 

The  iron  and  arsenic  may  advantageously  be  alternated  with  pure 
cod-liver  oil — one  to  two  drams  after  meals — each  being  given  for 
seven  days.  Alcohol  should  form  no  part  of  the  medication  of  these 
children.  In  using  the  so-called  liquid  proprietary  foods,  it  is  to  be 
remembered  that  some  of  them  contain  a  considerable  percentage  of 
alcohol. 

INFANTILE  CONVULSIONS 

Convulsions  in  the  newly  born  are  usually  of  an  entirely  different 
nature  from  those  which  occur  after  the  third  month.  During  the 
early  days  of  life,  a  convulsion  is  always  a  matter  of  serious  import, 
as  it  frequently  is  the  result  of  a  birth  trauma  and  suggests  a  possibly 
serious  brain  lesion,  which  may  terminate  in  early  death  or  result  in 
spastic  paralysis  or  idiocy. 

An  appreciation  of  the  causes  of  convulsions  in  older  infants  and  in 
young  children  suggests  the  treatment.  The  predisposing  causes  are 
rachitis  and  other  forms  of  malnutrition.  While  the  rachitic  child  is 
particularly  susceptible,  the  most  vigorous  is  by  no  means  exempt  if 
the  exciting  cause  is  of  a  sufficient  degree  of  severity.  Uremic  con- 
vulsions (page  347)  are  always  preceded  by  evident  kidney  involve- 
ment, which  may  at  once  explain  the  cause  of  the  seizure.  The 
cause  in  at  least  90  percent  of  the  cases  is  an  irritation  within  the 
gastro-enteric  tract,  due  to  a  foreign  body  or  undigested  food,  or 
the  absorption  into  the  circulation  of  toxins — the  products  of  decom.- 
position  in  the  intestinal  contents.  In  two  of  my  patients  phimosis 
with  much  smegma  and  irritation  was  the  most  plausible  cause  of  the 
convulsions.  Both  had  had  several  convulsions,  which  were  not  re- 
peated after  circumcision  was  performed.  In  a  small  percentage 
of  the  cases  convulsions  are  the  earliest  manifestations  of  lobar  pneu- 
monia and  scarlet  fever.  In  fact,  a  convulsion  may  be  a  prodromal 
symptom  of  any  of  the  infectious  diseases.  One  of  my  patients  had 
repeated  convulsions  until  he  was  relieved  of  forty-three  large  round- 
worms. So  frequently  is  intestinal  toxemia  a  cause  that  when  a 
child  in  apparent  health  is  seized  with  a  convulsion,  it  is  safe  to 
assume  that  it  is  of  gastro-enteric  origin ;  if  such  should  not  be  the 
case,  the  treatment  directed  toward  relieving  the  digestive  tract  is 
always  advantageous,  even  if  the  convulsion  is  the  first  symptom  of 
lobar  pneumonia  or  meningitis. 

Treatment. — When  a  convulsion  occurs,  the  patient  should  at 
once  be  undressed  and  placed  in  a  warm  mustard  bath  (page  30) 
at  a  temperature  of  105°  F.  While  in  the  bath,  there  should  be 
a  brisk  friction  of  the  trunk  and  extremities,  particularly  the  latter. 


364  NERVOUS   DISORDERS 

At  the  same  time  an  attendant  may  give  an  injection  of  soap-water. 
In  a  great  majority  of  the  cases,  in  less  than  five  minutes  the  child 
will  show  evidence  of  a  return  to  consciousness.  As  soon  as  he  can 
swallow,  two  teaspoonfuls  of  castor  oil  should  be  given.  After  a 
seizure  the  patient  should  be  kept  very  quiet  for  twenty-four  or 
forty-eight  hours.  An  ice-bag  or  cold  cloths  should  be  applied  to 
the  head  and  a  guarded  hot-water  bottle  kept  at  the  feet.  The  diet 
should  be  of  the  lightest.  Chicken  broth,  weak  beef-tea  or  chicken- 
tea,  and  thin  gruels  should  constitute  the  nourishment  for  a  day  or 
two.  A  second  seizure  is  more  easily  produced  than  the  first,  and  a 
third  easier  than  the  second,  and  as  about  10  percent  of  the  cases 
of  epilepsy  are  the  outcome  of  infantile  convulsions,  it  is  the  physi- 
cian's duty  to  see  to  it  that  the  indiscretion  in  diet  which  caused 
the  first  attack  is  not  repeated. 

In  case  the  attack  is  a  very  severe  one,  when  the  child  is  slow  to 
respond  or  when  he  passes  rapidly  from  one  convulsion  to  another, 
chloroform  inhalations,  regardless  of  the  age,  should  be  given  in  sufh- 
cient  quantity  to  prevent  the  seizures  until  the  intestinal  canal  can 
be  emptied  and  sufficient  sodium  bromid  and  chloral  can  be  given  by 
mouth  or  rectum  to  prevent  a  recurrence.  For  a  child  under  one 
year  of  age,  eight  grains  of  sodium  bromid  and  three  grains  of 
chloral  may  be  given  by  rectum  in  four  ounces  of  mucilage  of  acacia. 
After  the  first  year,  from  three  to  five  grains  of  chloral  may  be  given 
with  from  ten  to  twenty  grains  of  sodium  bromid.  It  is  best  to 
attach  to  the  syringe  a  soft-rubber  catheter.  No.  18  American,  or 
a  small  rectal  tube.  The  catheter  should  be  introduced  for  at  least 
nine  inches,  so  that  the  solution  may  be  carried  to  the  descending 
colon,  where  it  will  better  be  retained  than  if  introduced  with  the 
small  hard-rubber  tip  simply  within  the  anus.  The  bromid  and 
chloral  may  be  repeated  at  intervals  of  from  two  to  six  hours,  as 
required  to  control  the  convulsions,  and  continued  in  diminished 
doses  as  long  as  there  are  noticeable  signs  of  nervous  irritabihty, 
such  as  twitching  and  involuntary  muscular  contractions.  If  the 
child  can  swallow,  five  grains  of  sodium  bromid,  in  one-half  ounce  of 
water,  may  be  given,  and  repeated  at  intervals  of  from  one  to  four 
hours,  until  the  convulsions  are  controlled.  Morphin  hypoder- 
maticallv  is  rarely  required.  It  should  be  used  only  when  other 
measures  fail.  A  child  one  year  of  age  may  be  given  g'g-  grain,  which 
mav  be  repeated  in  two  hours,  though  usually  it  will  not  be  necessary. 
Under  one  year  ^q  to  -^^  grain  may  be  given;  under  six  months, 
morphin  would  better  be  omitted. 

Convulsions  should  never  be  lightly  regarded.  They  may  be  seri- 
ous in  their  immediate  as  well  as  in  their  remote  possibilities.  One 
convulsion  may  produce  cerebral  hemorrhage  which  may  change  the 
entire  future  of  the  patient,  producing  spastic  paralysis  or  idiocy, 
or  both.     About  10  percent  of  the  cases  of  epilepsy  originate  in  indi- 


GYROSPASM — SPASMUS    NUTANS  365 

gcstion — the  so-called  "dentition  convulsions."  In  these,  rachitis 
plays  an  important  etiologic  part.  It  is  the  duty  of  the  physician,  in 
a  given  case,  to  ascertain  the  cause  and  so  direct  the  future  manage- 
ment of  the  patient  as  to  avoid  a  recurrence  of  the  attack. 

Under  my  observation  several  children  under  one  year  of  age,  in 
apparently  good  health,  have  died  of  convulsions.  In  one  we  found 
at  autopsy  one-eighth  of  an  orange  in  the  small  intestine.  In  six, 
the  convulsions  were  due  to  enlarged  thymus  glands.  In  three  of 
these  cases  there  were  no  previous  symptoms  of  the  existence  of  this 
condition  (page  449).  They  were  strong  robust  infants.  Two  of 
them  were  breast-fed.  The  diagnosis  was  confirmed  by  autopsy  in 
four,  which  included  the  breast-fed. 

NIGHT-TERRORS 

In  night-terrors  the  child  arouses  from  his  sleep  frightened,  and 
sometimes  imagines  that  animals  or  persons  are  trying  to  injure  him. 
In  a  great  majority  of  cases  these  phenomena  are  due  to  a  deranged 
digestion  in  a  neurotic  child.  The  attacks  are  very  hable  to  follow 
indulgence  in  unusual  articles  of  diet,  and  when  they  occur  repeatedly, 
it  will  usually  be  found  that  the  child  is  suffering  from  persistent 
intestinal  indigestion  or  that  the  evening  meal  is  habitually  beyond 
his  digestive  capacity.  Children  subject  to  night-terrors  should 
dine  at  midday.  The  evening  meal  should  consist  of  cereals,  milk, 
stale  bread  and  butter,  and  a  small  portion  of  stewed  fruit.  The 
patient  should  never  be  allowed  to  go  to  bed  unless  an  evacuation 
of  the  bowels  has  taken  place  during  the  previous  twenty-four  hours. 

Overwork  at  school  and  anxiety  regarding  school  duties  and 
lessons  are  often  contributory  factors  to  night-terrors.  The  cases 
usually  are  readily  relieved  by  proper  treatment.  If  the  case  is 
an  aggravated  one,  the  child  should  be  removed  from  school,  and  all 
exciting  play  and  books  of  an  exciting  nature  forbidden. 

One  of  my  patients,  a  boy  who  was  four  years  of  age  when  he 
first  came  under  my  care,  has  had,  during  the  past  five  years,  two 
attacks  of  night-terrors  every  year.  One  attack  occurs  on  the  night 
of  his  birthday  and  the  other  on  Christmas  night.  At  these  times,  in 
spite  of  my  warnings  and  the  repeated  attacks,  he  is  indulged  by 
his  parents. 

In  the  very  nervous  and  irritable  cases  from  five  to  ten  grains 
of  bromid  of  soda  may  be  given  at  bedtime.  This  should  not  be 
continued  longer  than  a  week.  If  the  child  is  delicate,  anemic, 
or  suffering  from  adenoids,  enlarged  tonsils,  or  thread-worms,  these 
conditions,  any  one  of  which  may  contribute  to  night-terrors,  should 
receive  proper  treatment. 

GYROSPASM— SPASMUS  NUTANS 
Gyrospasm  is  a  functional  nervous  affection  usually  seen  in  chil- 
dren under  one  year  of  age.     I  have  seen  one  case  in  a  child  fourteen 


366  NERVOUS   DISORDERS 

months  of  age.  The  disorder  consists  in  a  rotatory  movement  of 
the  head,  sometimes  from  twenty  to  forty  oscillations  being  made 
in  a  minute.  The  movement  may  not  only  be  lateral  but  vertical 
also,  which  constitutes  what  is  known  as  "head-nodding."  In 
one  of  my  patients  both  the  lateral  and  the  vertical  movements 
took  place.  The  oscillations  are  usually,  but  not  invariably,  asso- 
ciated wuth  nystagmus.  I  have  seen  a  number  of  these  cases  in 
out-patient  clinics.  Rachitis  was  present  in  all.  Two  of  the  children 
were  idiots. 

The  prognosis  is  good  if  the  patient  is  mentally  normal.  It 
is  difficult  to  state  the  length  of  time  required  before  the  move- 
ments will  cease.  It  is  doubtless  a  matter  of  several  months.  With 
a  disorder  essentially  chronic  in  character,  the  improvement  is  slow. 
The  mother  becomes  dissatisfied  with  the  treatment  and  wanders 
from  clinic  to  clinic  with  her  child.  This  probably  explains  in  part 
the  large  number  of  individual  cases  seen  by  pediatrists.  I  have 
had  the  opportunity  to  give  a  few  cases  a  fair  trial  with  sodium 
bromid — from  twelve  to  eighteen  grains  daily — a  treatment  which 
is  generally  advocated  for  this  condition,  but  have  failed  to  note 
any  special  benefit  from  its  use.  With  an  increase  in  age  and  im- 
provement in  nutrition,  the  cases  which  I  have  followed  at  their 
homes  have  gradually  improved  and  recovered. 

TETANY 
Tetany  occurs  oftentimes  in  association  with  or  following  ex- 
haustive diseases.  It  may  occur,  however,  without  any  such  rela- 
tion to  other  affections.  In  my  cases  there  have  invariably  been 
rachitis,  malnutrition,  and  intestinal  indigestion  of  a  pronounced 
type.  The  muscular  spasms  may  involve  any  portion  of  the  body, 
but  the  extremities  are  most  frequently  affected. 

Treatment. — Inasmuch  as  intestinal  toxemia  and  malnutrition 
are  the  apparent  causes  of  the  phenomena,  attention  directed  to  the 
intestinal  canal  and  nutrition  is  indicated.  The  child  should  be 
given  two  drams  of  castor  oil,  and  milk  should  be  excluded  from 
the  diet  for  a  day  or  two  until  the  stools  become  normal.  This 
treatment  alone  has  cleared  up  some  of  my  cases.  When  the  spasm 
persists,  bromid  of  soda  should  be  given  in  two-grain  doses  every 
two  hours,  giving  at  least  six  doses  in  twenty-four  hours,  for  a  child 
one  year  of  age  or  younger.  The  patient  should  be  kept  very  quiet 
during  an  attack,  as  undue  excitement  may  precipitate  an  attack 
of  laryngismus  stridulus  or  convulsions  which  may  be  of  a  very 
serious  nature.  A  hot  bath  at  iio°  F.  for  a  few  moments,  and 
repeated  at  six-hour  intervals,  will  often  have  the  desired  relax- 
ing effect. 

The  later  treatment  consists  in  regulating  the  child's  nutri- 
tion.    If  the  malnutrition  is  extreme  or  if  the   infant  is  under  six 


CHOREA — ST.    VITUS'    DANCE  367 

months  of  age  a  wet-nurse  is  the  safest  means  of  nutrition.  A 
wet-nurse,  however,  is  not  practicable  in  children  beyond  one  year 
of  age.  There  is  considerable  uncertainty  as  to  how  these  older 
children,  those  approaching  the  twelfth  month,  will  take  the 
breast.  When  the  wet-nurse  is  impossible  or  impracticable,  an 
adjustment  of  the  food  to  the  child's  digestive  capacity  is  demanded 
along  the  Unes  laid  down  in  the  section  on  Malnutrition. 

Not  a  few  of  the  infants  who  develop  tetany  have  been  on  a 
low  proteid  such  as  is  furnished  by  the  proprietary  foods  and  con- 
densed milk,  or  they  may  have  had  a  low  proteid  capacity,  which, 
as  far  as  the  nutrition  is  concerned,  is  practically  the  same  thing. 
The  proteid  elements  in  the  diet,  therefore,  should  be  kept  well  in 
mind  in  feeding  these  cases.  It  is  in  such  cases  that  peptonized 
milk  (page  115)  is  indicated.  The  milk  should  always  be  given 
raw  unless  the  station  in  life  or  season  of  the  year  forbids  it. 

When  it  is  possible,  children  who  have  had  tetany  should 
in  every  instance  be  given  the  advantages  furnished  by  climate. 
An  outdoor  life  in  the  country  with  open  windows  at  night 
are  necessary  for  rapid  relief  of  the  weakened  physical  condi- 
tion which  underlies  the  disorder.  The  patient  should  be  given 
a  brine  bath  (page  31)  at  bedtime.  It  is  followed  by  inunc- 
tion with  an  animal  fat  during  the  cooler  months,  goose  oil  being 
preferred.  As  these  patients  are  usually  suffering  from  a  secondary 
anemia,  one-half  grain  of  the  citrate  of  iron  and  ammonium  may  be 
given  twice  or  three  times  daily  after  feeding.  The  hygienic  and 
dietetic  management  of  these  cases  is  practically  the  same  as  that 
suggested  for  marasmus  and  malnutrition. 

CHOREA— ST.  VITUS'  DANCE 

The  management  of  chorea  depends  entirely  upon  the  degree 
of  severity  of  the  attack.  It  may  be  necessary  in  extreme  cases 
to  keep  the  child  in  bed  from  three  to  four  weeks.  In  other  cases, 
where  the  attack  is  milder  in  character,  the  enforced  rest  may  do 
harm.  Formerly  I  treated  more  cases  on  the  extreme  rest  plan 
than  I  do  at  present.  For  cases  in  which  the  involuntary  move- 
ments are  so  marked  as  to  interfere  with  locomotion  and  prevent 
the  child's  feeding  himself,  rest  in  bed  for  a  week  or  two  is  strongly 
advised.  In  my  observation,  it  is  mental  repose  which  the  patients 
particularly  require,  and  if  this  can  best  be  obtained  in  bed, 
then  the  bed  is  the  best  place  for  the  patient.  If  an  absence  of 
mental  excitement  and  stimulation  can  be  secured  with  a  reason- 
able amount  of  outdoor  life  and  exercise,  so  much  the  better  for 
the  patient.  An  important  feature  to  be  remembered  in  the  manage- 
ment of  choreic  children  is  that  they  must  not  be  allowed  to  become 
fatigued  either  physically  or  mentally. 

In  the  cases  which  have  been  confined  to  the  bed  for  several 


368  NERVOUS    DISORDERS 

days  or  weeks,  a  gradual  return  to  the  usual  habits  is  best.  The 
child  should  be  taken  up  for  one-half  hour  the  first  day,  increasing 
the  time  out  of  bed  one-half  hour  daily,  until  he  returns  to  his  usual 
habits  of  life.  School  for  the  choreic  patient  is  out  of  the  question, 
no  matter  how  mild  the  case.  In  the  great  majority  of  cases,  play 
with  other  children  will  have  to  be  interdicted.  Books  and  play 
of  an  exciting  nature  are  particularly  to  be  avoided.  Specific 
instructions  as  to  the  amount  of  physical  and  mental  rest  required 
cannot  be  given  so  as  to  apply  generally  in  the  management  of 
chorea.  The  physician  should  particularly  remember  that  there 
must  be  no  bodily  fatigue  and  no  mental  stimulation  of  any  nature 
whatever.  How  best  to  bring  this  about  will  depend  upon  the 
child  and  his  environment. 

In  two  instances  I  have  been  obliged  to  remove  the  child  from 
his  home  and  place  it  among  relatives.  The  influence  of  the  mother 
was  such  as  hopelessly  to  prevent  the  child's  recovery.  Cases 
not  sufficiently  severe  for  confinement  in  bed,  should  be  made  to 
rest  for  two  hours  every  day  after  dinner. 

Striimpell  in  his  text-book  states  that  the  association  of  chorea 
and  rheumatism  is  so  close  that  it  is  impossible  to  separate  them. 
Hirt,  in  discussing  ner\'ous  diseases,  expresses  the  view  that  there 
is  a  common  toxic  etiologic  factor  which,  affecting  the  cortex,  pro- 
duces chorea ;  but  affecting  the  joints,  gives  rise  to  acute  articular 
rheumatism.  That  the  association  of  chorea  and  rheumatism  is 
a  most  intimate  one,  has  been  borne  out  by  the  observations  of 
many  cUnicians.  A  trifle  over  50  percent  of  my  cases  of  chorea 
either  gave  a  history  of  having  shown  rheumatic  manifestations, 
or  thev  showed  evidence  of  it  when  first  seen.  In  80  percent  of  my 
cases  there  was  some  association  with  rheumatism,  either  in  rheumatic 
parents  or  in  the  actual  manifestations  of  rheumatism  at  some  time 
in  the  patient's  life.  So  impressed  have  I  been  by  the  above  facts, 
and  by  the  similarity  of  the  clinical  signs  of  these  supposedly  distinct 
diseases,  that  I  believe  them  due  to  the  same  toxic  agent.  This 
is  further  proved  by  the  results  of  treatment. 

Anti-rheumitic  Treatment. — By  treating  every  case  of  chorea 
as  though  it  were  rheumatism,  my  results  have  been  strikingly 
better.  Not  only  is  the  child  given  the  salicylates,  but  he  is 
put  on  an  anti-rheumatic  diet  —  given  meat  but  once  even,^  sec- 
ond dav,  and  but  little  sugar.  The  salicylate  of  soda  may  be  given 
in  smaller  doses  than  are  used  in  acute  articular  rheumatism — about 
five  grains  three  times  daily,  with  an  equal  amount  of  the  bicar- 
bonate of  soda,  being  suitable  for  a  child  from  six  to  ten  years  of 
age,  the  soda  being  given  between  meals.  To  children  of  this  age 
the  salicylate  may  be  given  either  in  capsule  or  in  solution.  In 
young  children,  the  drugs  in  solution  are  more  easily  administered. 
During  the  past  year  I  have  given  aspirin  to  a  few  patients  in  whom 


CHOREA — ST.    VITUS'    DANCE  369 

the  digestive  functions  were  weak  or  who  could  not  take  the  saU- 
cylate  of  soda.  In  using  the  saHcylate  of  soda,  Merck's  or  Squibb's 
preparation  should  always  be  indicated.  In  using  salicylate  of 
soda  or  aspirin  for  a  considerable  time,  it  is  well  to  remember  that 
they  may  interfere  with  the  appetite  and  digestion,  no  matter  how 
great  the  care  exercised  in  their  use.  For  this  reason  it  is  my  custom 
to  give  them  intermittently — five  days  of  medication  being  fol- 
lowed by  five  days  of  rest. 

I  have  found  that  by  putting  the  patient  on  the  anti-rheumatic 
treatment  much  less  arsenic  is  required,  and  that  the  patient  usually 
makes  a  more  prompt  recovery.  I  have  never  been  olaliged  to  resort 
to  the  large  dosage  of  twenty-five  to  thirty  drops  of  Fowler's  solution 
three  times  a  day,  as  suggested  by  Seguin.  It  is  exceedingly  rare 
that  it  is  necessary  to  give  more  than  ten  drops  three  times  daily 
in  order  to  procure  satisfactory  results.  In  spite  of  the  value  of 
the  anti-rheumatic  treatment  this  alone  will  not  answer,  as  I  have 
proved  to  my  satisfaction  in  not  a  few  cases.  The  administration 
of  the  arsenic  and  the  salicylate  and  the  dietetic  regime  are  begun 
at  the  same  time.  The  salicylate  of  soda  is  given  at  once  at  the 
commencement  of  the  treatment  in  as  full  doses  as  we  expect  to 
give  it.  Arsenic  is  commenced  in  small  doses,  which  are  grad- 
ually increased  in  order  to  establish  a  tolerance  of  the  drug.  Fowler's 
solution  of  arsenic  is  usually  employed.  In  order  that  no  error 
be  made  in  its  administration,  a  table  similar  to  the  following  is 
given  to  the  mother  or  attendant.  For  a  child  six  years  of  age 
on  the  first  day  after  each  meal,  two  drops  should  be  given  as  indi- 
cated below.  Thereafter,  the  dosage  is  increased  by  one  drop  every 
twenty-four  hours,  according  to  the  following  schedule : 

DOSAGE    OF    fowler's    SOLUTION    FOR  A    CHILD    SIX    YEARS    OLD 

1st    day — Morning,  2  Drops.      Noon,  2  Drops.      Nis;ht,  2  Drops 
2d       "■             "         2        "               "2         "  ^"      3       " 

3d       "  "         2        "  "3         "  "      3       " 

4th     "  "         3        "  "3         "  "      3 

This  rate  of  daily  increase  is  continued  up  to  the  third  week, 
after  which  time  the  dosage  should  range  from  five  to  ten  drops 
three  times  a  day.  For  a  child  of  from  eight  to  ten  years  of 
age  the  amount  may  be  increased  to  from  twelve  to  fifteen  drops 
three  times  a  day.  I  have  never  found  it  necessary  to  give  more 
than  twelve  drop  doses  to  girls  of  from  thirteen  to  sixteen  years 
old.  A  very  recent  aggravated  case  in  a  girl  fifteen  years  of  age 
made  a  complete  recovery  in  three  weeks  under  the  above  scheme 
of  diet,  the  use  of  aspirin,  ten  grains  daily  after  meals,  and  Fowler's 
solution  up  to  twelve  drops  after  each  meal.  With  the  improvement 
of  the  case,  the  diet  should  be  continued.  The  medication  may  grad- 
ally  be  reduced  after  all  the  symptoms  have  disappeared.  It  should 
24 


370  NERVOUS   DISORDERS 

be  continued,  however,  in  from  one-third  to  one-half  the  quantity, 
for  three  weeks  after  the  disappearance  of  all  nervous  symptoms. 

Supplementary  Treatment. — It  should  be  remembered  that 
children  who  have  once  had  chorea  are  very  susceptible  to  recur- 
rent attacks.  This  is  also  the  case  with  children  who  have  had 
rheumatism.  After  one  attack  of  chorea  the  danger  of  a  return  is 
explained  to  the  mother,  who  is  asked  to  bring  the  child  for  exami- 
nation at  the  first  suggestion  of  involuntary  muscular  twitching. 
In  addition  to  this,  children  who  have  had  chorea,  as  well  as  those 
who  have  had  rheumatism,  are  allowed  meat  but  once  every  second 
day,  and  in  no  case  is  an  excessive  use  of  sugar  permitted.  Candy 
is  usually  forbidden.  Believing  that  these  cases  are  rheumatic  in 
origin,  when  the  attack  is  over  I  order  the  child  to  receive  ten  grains 
of  bicarbonate  of  soda  daily  for  five  days  out  of  every  fifteen.  In 
this  way,  with  a  reasonably  quiet  home  life  and  no  school  contests 
for  prizes,  etc.,  a  recurrence  will  in  all  probability  be  prevented.  In 
giving  arsenic,  mothers  are  advised  that  in  the  event  of  abdominal 
pain,  diarrhea,  coated  tongue,  foul  breath,  vomiting,  or  puffiness 
under  the  eyes,  the  drug  is  to  be  discontinued  for  at  least  two 
days.  Upon  resuming  it,  the  minimum  dose  is  again  given  with 
the  same  gradual  increase. 

Children  vary  greatly  as  to  their  tolerance  of  arsenic.  A  boy 
seven  years  old,  under  my  care  at  the  present  time,  cannot  take 
more  than  four  drops  of  Fowler's  solution  three  times  a  day. 

HABIT  SPASM 

By  habit  spasm  we  understand  a  semi-incoordinate  movement 
of  some  portion  of  the  body.  The  term  "semi-incoordinate"  is 
used  advisedly,  because  the  spasm  may  be  controlled  when  the 
child's  attention  is  directed  to  it,  this  being  one  of  its  distinguish- 
ing features.  The  muscles  involved  in  the  spasm  are  usually  those 
of  the  head,  face,  or  arm.  The  nose  may  be  drawn  up,  the  chin 
down,  or  the  head  to  either  side.  The  muscular  spasm  is  worse 
when  the  patient  is  tired  and  occurs  more  frequently  under  excite- 
ment. While  these  children  cannot  be  said  to  have  chorea,  there 
is  a  close  association  of  the  two  conditions,  there  being  but  a  step 
from  habit  spasm  to  true  chorea.  Habit  spasm  is  most  frequently 
seen  in  those  of  rheumatic  inheritance — those  who  have  had  previ- 
ous attacks  of  chorea  or  rheumatism  or  the  respiratory  manifes- 
tations so  frequentlv  seen  in  children  of  the  rheumatic  type. 

Treatment. — The  management  is  dietetic,  hygienic,  and  medi- 
cinal. I  allow  these  patients  a  small  portion  of  red  meat  once  a 
dav.  Sugar  is  given  in  sufficient  amount  to  make  the  food  pala- 
table. The  vegetable  and  legume  element  in  the  diet  is  made 
prominent.  The  patient  will  usually  be  found  poorly  nourished, 
often  he  is  suffering  from  a  secondary  anemia,  so  that  a  diet  best 


EPILEPSY 


371 


calculated  to  improve  his  general  condition  should  be  prescribed. 
He  should  be  given  a  salt  bath  (page  31)  at  bedtime,  followed  by 
an  oil  rub  one  ounce  of  goose  oil,  unsalted  lard,  or  olive  oil  being 
rubbed  into  the  skin  immediately  after  the  bath. 

Temporary  absence  from  school  or  a  lightening  of  school  duties 
and  an  outdoor  Hfe  are  of  much  aid  in  the  successful  management 
of  a  case.  The  child  should  not  be  allowed  to  do  anything  of  a 
strenuous  nature.  Hard  play  and  any  amusements  of  an  exciting 
character  are  to  be  forbidden.  Fatigue  must  be  avoided.  Rest 
after  the  noon-day  meal  for  an  hour  or  two  is  strongly  recommended. 

As  to  medication,  the  scheme  suggested  for  chorea  is  also  appli- 
cable here.  If  there  is  anemia,  iron  is  given,  preferably  in  the  form  of 
the  extractum  ferri  pomatum,  1  grain  three  times  a  day.  In  those 
children  who  cannot  take  cream  or  butter,  cod-liver  oil  in  teaspoonful 
doses  is  a  valuable  addition  to  the  treatment.  The  iron  may  be 
alternated  with  the  cod-liver  oil,  each  being  given  for  five  days. 
If  there  is  a  rheumatic  history  or  inheritance,  aspirin  or  salicylate 
of  soda,  preferably  aspirin,  is  given  in  capsule  with  the  iron.  The 
following  is  a  favorite  prescription  for  a  child  five  vears  of  age : 

I^.      Liquoris  potassii  arsenitis gtt.  iij 

Extract!  ferri  pomatum o^r   ss 

Aspirin '  .  '  .'  '  '|r!  iij 

Sig. — One  dose;  to  be  given  in  capsule  after  each  meal. 

The  use  of  arsenic,  while  of  advantage,  does  not  appear  to  be  as 
valuable  here  as  in  chorea. 

Habit  spasm  being  practically  under  the  control  of  the  will, 
should  be  strictly  forbidden,  rewards  being  given  and  punishments 
imposed,  as  seem  to  answer, best. 

EPILEPSY 

While  the  underlying  conditions  as  regards  the  pathology  and 
etiology  of  epilepsy  are  better  understood  as  a  result  of  the  'study 
which  has  been  devoted  to  the  subject  during  the  past  few  years, 
our  knowledge  as  to  the  successful  treatment  of  the  disease  has  not 
increased  materially,  if  we  are  to  judge  from  the  recent  writings 
of  the  best  authors.  While  appreciating  the  value  of  workers  hi 
this  field,  I  am  sure  that  there  is  a  disposition  on  the  part  of  some 
writers  to  draw  too  narrow  lines  of  differentiation  between  different 
types  of  the  disease. 

Treatment. — In  the  management  of  epilepsv  we  can  promise  little 
or  nothing  as  to  cure,  and  practicallv  all  we  can  hope  to  do  is  to 
diminish  the  frequency  of  the  attacks  which  characterize  the  dis- 
ease, whether  it  be  a  grand  mal  or  a  petit  mal.  Proper  nutrition, 
rational  habits  of  living,  and  pleasant  outdoor  occupations  are  of 
inestimable  service  in  the  management  of  the  epileptic.  The 
method  of  management  which  has  served  me  best  has  been,  first. 


372  NERVOUS   DISORDERS 

along  general  and  hygienic  lines ;  and,  second,  by  the  use  of  drugs. 
It  should  be  our  object  to  make  thv=^  patient  physically  as  normal, 
as  vigorous,  and  as  resistant  to  attacks  as  lies  in  our  power. 

Visual  defects,  enlarged  tonsils,  adenoids,  phimosis,  and  irritant 
skin  lesions  must  all  be  corrected  before  beneficial  results  are  to 
be  expected  from  any  line  of  treatment.  The  patient  is  then 
placed  under  the  best  possible  environment  permitted  by  his  station 
in  life.  Outdoor  life,  sports,  and  games  are  encouraged,  always 
keeping  within  the  lines  of  moderation.  The  child  should  sleep 
in  a  cool  room  with  the  freest  possible  ventilation  at  all  seasons  of 
the  year.  If  he  is  a  school-child,  he  is  instructed  at  home  and  the 
sessions  are  made  short  and  the  studies  easy.  The  patient  in  his 
work  or  play  is  never  allowed  to  reach  the  point  of  mental  or 
physical  fatigue.  This,  to  my  mind,  is  most  important.  Emotional 
plays  at  the  theater  and  exciting  amusements  elsewhere  are  forbid- 
den. 

The  diet  is  to  be  adjusted  to  the  child's  digestive  capacity.  A 
diet  suitable  for  his  age  is  given,  just  as  for  normal  children  (page 
128),  meat  being  allowed  only  once  a  day.  As  intestinal  indigestion 
and  toxemias  from  intestinal  sources  are  unquestionably  important 
etiologic  factors  in  not  a  few  cases  in  causing  a  recurrence  of  the 
seizures,  careful  attention  to  the  bowel  function  and  diet  are  most 
important  features  of  the  treatment.  The  epileptic  patient  under 
my  care  is  never  allowed  to  pass  over  twenty-four  hours  without  an 
evacuation  of  the  bowels,  and  if,  in  the  opinion  of  those  in  charge, 
it  is  not  as  copious  as  usual,  an  enema  is  given.  If  there  is  a  sug- 
gestion of  constipation,  the  treatment  with  the  oil  enemata,  as  re- 
commended for  chronic  constipation  (page  167),  is  instituted.  In 
cases  in  which  heredity  and  toxic  influences  prevail,  the  im- 
portance of  attention  to  the  diet  and  habits  of  life  cannot  be 
overestimated.  When  there  is  a  focal  lesion,  attention  to  the  details 
of  living  will  have  less  influence,  but  always  surely  some  influence, 
in  diminishing  the  frequency  and  severity  of  the  seizures  by  es- 
tablishing a  more  vigorous  physical  resistance. 

Among  those  who  are  unable  to  give  the  patient  suitable  atten- 
tion at  home  I  urge  that  he  be  placed  in  one  of  the  excellent  insti- 
tutions devoted  to  the  care  of  epileptics. 

There  are  few  drugs  in  the  pharmacopeia,  particularly  those 
of  a  sedative  nature,  that  have  not  been  used  at  one  time  or 
another  in  the  treatment  of  epilepsy.  The  bromids  unquestionably 
serve  our  purpose  in  controlling  the  seizures  better  than  does  any 
other  form  of  medication.  The  size  of  the  dose  is  variable.  Because 
of  their  peculiarly  depressing  effects  upon  the  child's  mental  con- 
dition, the  bromids  should  be  given  in  as  small  quantities  as  are 
compatible  with  the  beneficial  results  desired — a  diminution  of  the 
number  of  the  convulsions.     Ordinarily  ten  grains  of  sodium  bromid 


MENINGITIS  373 

may  be  given,  well  diluted,  in  one-half  glass  of  water  after  meals, 
to  a  child  ten  years  old,  the  amount  to  be  increased  or  diminished  as 
the  progress  of  the  case  demands.  If  the  convulsions  are  nocturnal, 
large  doses — from  twenty  to  thirty  grains — should  be  given  at  bed- 
time to  a  child  of  ten  years.  In  the  event  of  the  drug  being  discon- 
tinued to  the  point  where  it  is  given  but  once  a  day,  the  time 
selected  should  be  bedtime.  With  continued  improvement  under 
the  bromid,  it  may  be  given  on  alternate  nights,  and  then  every 
fourth  night. 

Illustrative  Case. — I  have  now  under  my  care  a  case  which 
I  have  treated  for  several  years  and  which  promises  well.  The 
first  convulsion  occurred  at  the  fifteenth  year.  It  was  a  typical 
nocturnal  seizure.  Fifteen  grains  of  bromid  with  five  drops  of  the 
tincture  of  belladonna  were  given  three  times  daily  for  three  months, 
when  the  amount  was  reduced  to  thirty  grains  daily.  This  was 
continued  for  one  month,  when  a  death  occurred  in  the  family 
which  doubtless  helped  to  incite  a  second  attack.  At  this  time, 
the  patellar  reflex  being  scarcely  perceptible  and  the  bromid  rash 
considerable,  the  drug  was  discontinued.  At  the  end  of  two  months 
the  daily  dosage  was  placed  at  twenty  grains,  with  ten  drops  of 
the  tincture  of  belladonna.  This  was  continued  for  four  weeks, 
when  there  was  a  third  attack,  without  any  apparent  cause  of  an 
exciting  nature,  but  the  patient  had  allowed  herself  to  become  obsti- 
nately constipated.  This  was  her  last  attack.  Three  years  have 
since  intervened.  The  bromid  has  been  gradually  reduced,  first 
to  ten  grains  daily  at  bedtime,  then  every  other  day,  and  now  it 
is  taken  every  fourth  day  only. 

MENINGITIS 

Holt's  classification  of  meningitis  as  epidemic  cerebrospinal, 
acute  simple  (due  to  the  pneumococcus  or  other  pyogenic  organisms) , 
and  tuberculous,  covers  the  matter  of  division  of  types  better  than 
any  other. 

The  management  of  the  different  forms  of  meningitis  is,  in  the 
main,  the  same,  and  I  know  of  no  disease  in  children  in  which  so 
little  hope  is  to  be  held  out  for  the  patient.  A  certain  proportion 
of  the  cases  of  cerebrospinal  meningitis  recover,  but  the  recovery 
or  fatal  issue  is  governed  by  the  character  of  the  infection,  to  an 
extent  greater  than  perhaps  we  are  willing  to  admit.  The  immediate 
mortality  in  the  different  epidemics  of  cerebrospinal  meningitis 
varies  from  60  to  90  percent.  Not  a  few  of  those  who  survive  were 
better  dead.  As  to  the  number  of  such  cases  which  recover  with 
normal  mentality,  normal  coordination,  vision,  and  hearing,  statis- 
tics are  very  unsatisfactory.  I  have  had  not  a  few  of  the  so-called 
cured  cases  admitted  to  my  hospital  wards  who  will  be  hopeless 
invalids  for  the  remainder  of  their  lives.     I  have  seen  cases  of  cerebro- 


374  NERVOUS    DISORDERS 

spinal  meningitis  so  mild  that  a  diagnosis  could  not  have  been  posi- 
tive without  a  lumbar  puncture,  and  which  recovered  without 
treatment,  and  I  have  seen  cases  so  severe  that  the  patient  died  in 
twenty-four  hours  in  spite  of  every  known  means  of  relief. 

The  most  severe  cases,  however,  should  not  be  despaired  of  in 
spite  of  the  decidedly  hopeless  outlook.  I  saw  a  case  at  different 
times  in  consultation  during  the  recent  epidemic  in  New  York  city — 
a  boy  six  years  of  age  who  was  confined  to  his  bed  for  fourteen 
weeks,  unconscious  for  four  weeks,  blind  for  four  weeks,  and  deaf 
for  five  weeks,  who  was  unable  to  swallow  and  was  nourished 
by  rectal  enemata  for  two  weeks,  and  yet,  according  to  the  state- 
ment of  his  family  physician,  he  made  an  excellent  recovery  and 
is  normal  in  every  respect.  Physicians  who  pursue  a  special  line 
of  treatment,  and  who  have  the  good  fortune  to  meet  with  mild 
cases,  sometimes  become  optimistic,  and  feel  that  their  special 
scheme  of  management  is  the  one  to  be  depended  upon;  further 
observations,  however,  prove  the  futility  of  their  methods. 

Treatment. — The  most  we  can  do  in  cerebrospinal  meningitis  is 
to  nourish  the  patient  and  lessen  his  discomfort,  and  in  this  way  aid 
him  to  resist  the  infection.  By  the  use  of  repeated  lumbar  punc- 
ture, we  can,  in  the  majority  of  the  cases,  appreciably  relieve  the 
patient.  The  pulse  and  the  respiration  improve  and  the  urgency  of 
the  nervous  phenomena,  the  opisthotonos,  and  the  excessive  hy- 
peresthesia may  be  temporarily  relieved.  There  are  no  rational 
grounds  for  expecting  lumbar  puncture  to  be  curative,  neither  may 
the  injection  of  disinfectant  drugs  into  the  canal  be  expected  to 
aid  in  controlling  the  disease. 

Lumbar  Puncture. — Lumbar  puncture  (page  376)  may  be  prac- 
tised as  frequently  as  once  in  twenty-four  hours,  the  frequency 
of  its  use  depending,  of  course,  upon  the  condition  of  the  patient 
and  the  relief  afforded.  Its  more  frequent  use  than  once  in 
twenty-four  hours,  as  has  been  suggested,  is  not,  however,  to  be 
advised.  The  amount  of  fluid  withdrawn  depends  upon  the  pres- 
sure in  the  canal  as  indicated  by  the  passage  of  fluid  through  the 
canula,  from  one  to  three  ounces  being  the  usual  amount  withdrawn. 
The  usual  surgical  precautions  as  regards  asepsis  should  be  observed 
in  performing  the  operation.  One  dram  of  aristol  in  one  ounce  of 
collodion,  applied  with  a  camel's-hair  brush,  makes  a  suitable  pro- 
tective dressing  after  the  withdrawal  of  the  canula. 

Warm  Packs. — The  warm  pack  or  warm  bath  at  105°  F.,  by  les- 
sening the  cerebral  blood-pressure,  may  also  assist  in  relieving  the 
more  active  nervous  manifestations.  If  the  bath  is  used  the  child 
should  not  be  kept  in  it  longer  than  three  minutes.  I  usually  prefer 
the  hot  pack.  A  large  bath  towel  or  medium-weight  flannel  sheet  is 
wrung  out  of  water  at  110°  F.  and  wrapped  around  the  child's  body 
from  the  waist  down.     This  is  repeated  at  one-half -hour  intervals  for 


MENINGITIS  375 

three  hours,  when,  after  a  period  of  rest  for  an  hour  or  two,  the  packs 
may  be  resumed. 

Q{(,1 — Xhe  proper  nutrition  of  the  patient  with  meningitis  is 
oftentimes  a  matter  of  no  Uttle  difficuhy .  The  child  may  either  refuse 
the  food  or  he  may  be  unable  to  swallow.  Nutrition  by  means  of 
the  rectum  or  colon  may  be  of  assistance  for  a  few  days,  but  it 
cannot  be  relied  upon  for  long  periods.  The  parts  become  intolerant 
and  the  nutrient  enemata  are  expelled.  Feeding  by  means  of 
gavage  is  alwavs  to  be  employed  when  other  means  fail.  The 
younger  the  child,  the  greater  will  be  our  success  with  it.  The 
feeding  should  not  be  attempted  oftener  than  at  four-hour  intervals; 
usually  every  six  hours  suffices.  Completely  peptonized  full  milk 
(page  115)  is  usually  given  in  quantities  suitable  for  the  age.  After 
a  few  trials  of  gavage,  the  patient  may  take  the  nourishment  by 
the   usual   method   or   the    gavage    may   be   kept   up    indefinitely. 

Sedatives. — Sedatives  may  be  employed  with  a  view  to  saving  the 
strength  of  the  patient.  Morphin,  codein,  the  bromid  of  soda,  or  chlo- 
ral may  be  given.  As  morphin  and  codein  increase  the  usual  exist- 
ing constipation,  their  use  should  be  very  temporary.  The  bromid  of 
soda  for  those  cases  which  may  require  the  protracted  administra- 
tion of  a  sedative,  answers  better  than  any  other  form  of  medi- 
cation. For  an  infant  under  eighteen  months  of  age,  from  two  to 
four  grains  may  be  given  at  intervals  of  from  two  to  three  hours, 
according  to  the  results.  In  case  the  nervous  symptoms  are  very 
urgent,  one-half  to  one  grain  of  chloral  may  be  added.  Should 
administration  by  mouth  be  impracticable,  the  sedative  may  be 
given  by  rectum,  and  should  be  introduced  by  means  of  a  rectal 
tube  inserted  at  least  nine  inches.  In  using  the  bromid  and 
chloral  in  this  way,  twice  the  amount  of  chloral  and  thrice  the 
amount  of  bromid  should  be  given  that  is  employed  in  stomach 
administration.  After  the  eighteenth  month,  from  one  to  two 
grains  of  chloral  and  from  four  to  eight  grains  of  the  bromid  may  be 
given  by  stomach.  It  should  be  well  diluted  and  repeated  as  often 
as  may  be  necessary.  In  case  it  is  to  be  given  by  rectum,  it  should 
be  diluted  with  at  least  four  ounces  of  water,  and  proportionately 
more  given,  as  suggested  for  younger  children.  The  colonic  admin- 
istration of  salicylate  of  soda  in  cerebrospinal  meningitis  is  advised 
by  Seibert.  I  have  not  used  it  in  a  suihcient  number  of  cases  to 
warrant  an  expression  of  opinion  as  to  its  value. 

In  acute  pyogenic  meningitis  and  in  the  tuberculous  form,  the 
management  is  in  accordance  with  the  means  suggested  above,  with 
an  exception  of  the  hot  baths  or  packs,  which  are  rarely  called  for. 
The  lumbar  puncture  is  to  be  used  for  diagnostic  purposes  and  with 
a  view  to  relieving  the  urgency  of  the  nervous  symptoms. 

The  proved  cases  of  these  two  types  seen  by  me  have  invariably 
been  fatal.     Pyogenic  cases  live  perhaps  from  two  to  three  weeks. 


376 


NERVOUS    DISORDERS 


Tuberculous  cases  rarely  pass  the   sixth    week    after    the    appear- 
ance of  diagnostic  signs. 

LUMBAR  PUNCTURE 
The  site  selected  for  lumbar  puncture  is  a  point  parallel  with 
the  crests  of  the  ilia  and  between  the  spinous  processes  of  the  third 
and  fourth  lumbar  vertebrae.  The  child  should  rest  on  its  side 
(see  Fig.  40),  sufficient  pressure  being  exerted  on  the  buttocks 
to  make  the  spinous  processes  prominent.  The  Quincke  needle 
(Fig.  41)  should  always  be  used  in  making  the  puncture.  The 
stylet  which  fits  the  beveled  edge  of  the  point  of  the  needle  effect- 


L^ 


Fig.  40. — Position  for  and  Site  of  Lumbar  Puncture. 


ually  prevents  its  being  plugged.  The  skin  for  several  inches  about 
the  site  of  the  puncture  should  be  scrubbed  with  the  tincture  of 
green  soap  and  alcohol.  The  physician's  hands  should  be  thoroughly 
disinfected.     Considerable  force  may  be  necessary  in  order  to  enter 


Fig.  41.— Quincke's  Needle 


the  canal.  When  there  is  a  sudden  giving  way  of  the  obstruction 
to  the  progress  of  the  needle,  we  know  that  the  canal  has  been 
entered.  The  puncture  may  be  made  in  a  line  with  the  spinous 
processes  or  from  the  side,  the  needle  being  passed  between  the 
laminae.  When  the  point  of  the  needle  has  been  introduced  into 
the  spinal  canal,  the  stylet  is  withdrawn.     The  cerebrospinal  fluid 


CHRONIC    INTERNAL    HYDROCEPHALUS  377 

may  escape  with  force  in  a  stream  as  a  result  of  the  pressure  or  it 
may  exude  drop  by  drop.  A  sterile  tube  should  be  in  readiness 
in  order  to  collect  the  fluid  for  examination. 

Lumbar  puncture  is  often  of  value  for  diagnostic  purposes,  but 
its  therapeutic  value  is  practically  nil.  In  meningitis  the  with- 
drawal of  an  ounce  or  two  of  the  fluid  will  sometimes  furnish  tem- 
porary reUef  to  the  patient.  The  retraction  of  the  head  and  the 
spasticity  will  generally  be  relieved  for  a  time.  I  have  repeatedly 
withdrawn  the  fluid  in  such  cases,  where  there  was  a  tense  bulging  of 
the  fontanel,  and  after  two  or  three  hours  have  passed,  the  fontanel 
would  still  be  found  depressed;  it  would  soon  become  prominent, 
however,  and  in  eight  or  ten  hours  it  often  would  be  as  tense  as  be- 
fore. The  advantage  of  lumbar  puncture,  therefore,  is  largely  of  a 
diagnostic  nature,  only  temporary  reUef  being  furnished  the  patient 
by  the  operation.  The  introduction  of  drugs  into  the  canal  for 
bactericidal  purposes  is  valueless. 

CHRONIC  INTERNAL  HYDROCEPHALUS 

When  hydrocephalus  in  infants  is  mentioned  without  definite 
qualifications,  the  internal  is  always  the  type  referred  to,  the  external 
being  of  extreme  rarity.  The  discussion  of  this  aff"ection  will  neces- 
sarily be  brief,  for  after  the  treatment  of  a  considerable  number 
of  such  cases  in  hospitals  and  institutions  I  am  unable  to  recommend 
any  treatment  that  has  proved  of  the  slightest  value. 

A  new  operative  measure  is  now  being  employed  by  Dr.  A.  S. 
Taylor,  of  New  York,  which  consists  in  tapping  one  of  the  lateral 
ventricles  and  establishing  drainage  by  means  of  strands  of  chro- 
micized  catgut  conducting  the  fluid  to  the  subarachnoid  space, 
where  its  absorption  is  hoped  for.  The  operation  is  described  by 
Dr.  Taylor  as  follows: 

"An  osteoplastic  flap  about  two  inches  in  diameter  is  turned 
down,  with  its  hinge  over  the  base  of  the  mastoid  and  just  above 
the  level  of  the  horizontal  lateral  sinus.  In  the  lower  part  of  the 
dura  mater  thus  exposed,  a  semicircular  flap,  base  downward  and 
about  one  inch  in  diameter,  is  made.  Frequentlv  there  are  one 
or  two  distended  veins  beneath  this  dural  flap,  and  they  should  not 
be  damaged,  for  their  walls  are  so  friable  that  neither  clamp  nor 
ligature  is  of  much  use,  and  the  bleeding  is  annoying.  The  brain 
immediately  protrudes  through  this  dural  window.  A  slender 
aspirating  needle  is  passed  through  the  second  temporo-sphenoidal 
convolution  (which  is  the  one  protruding),  inward  and  slightly 
upward  until  it  enters  the  ventricle,  when  the  clear  fluid  spurts 
out  and  is  collected  in  a  sterile  tube  for  bacteriologic  examination. 
Only  a  A^ery  small  amount  should  be  allowed  to  escape  in  this  way. 

"The  thickness  of  the  brain  tissue  is  measured  by  observing  the 
length  of  needle  inserted  when  the  fluid  begins  to  escape. 


378  NERVOUS   DISORDERS 

"The  drain  is  now  made  of  No.  2,  forty-day,  chromic  catgut. 
Three  loops  (six  strands),  about  an  inch  and  three-quarters  longer 
than  the  thickness  of  the  brain,  are  bound  together  by  a  loose  spiral 
of  catgut,  starting  at  one  end  and  stopping  so  as  to  leave  an  inch 
and  a  quarter  of  the  loops  free.  In  other  words,  the  drain  consists 
of  a  shaft  of  six  strands  of  catgut  a  half -inch  longer  than  the  brain 
thickness,  and  spreading  from  its  base,  three  free  loops  of  gut  an 
inch  and  a  quarter  long.  Around  the  shaft  of  the  drain,  but  not 
covering  its  tip,  are  rolled  three  layers  of  cargile  membrane.  With 
a  long,  narrow-bladed  thumb  forceps  the  tip  of  the  drain  is  seized 
and  carried  into  the  ventricle  along  the  tract  made  by  the  aspirat- 
ing needle.  The  tip  projects  about  one-half  inch  into  the  ventricle. 
The  free  loops  of  gut  are  slipped  under  the  dura,  between  it  and  the 
brain  surface,  in  different  directions,  but  chiefly  downward  toward 
the  great  lymph  spaces  at  the  base  of  the  brain.  A  sheet  of  cargile 
membrane  is  sUpped  between  the  dura  and  the  catgut  loops  to  pre- 
vent adhesions.  Usually  by  this  time  sufficient  ventricular  fluid 
has  escaped,  so  that  the  brain  no  longer  protrudes  through  the  dural 
window.  The  dura  is  sutured  with  catgut,  the  bone-flap  is  held 
in  place  by  three  or  four  chromic  catgut  sutures,  the  deeper  soft 
tissues  by  catgut,  and  finally  the  skin  with  silk.  A  good-sized 
sterile  dressing  is  applied  with  some  pressure, 

"  The  site  just  above  and  behind  the  ear,  with  the  puncture 
through  the  second  temporo-sphenoidal  convolution,  was  chosen 
because  the  body  of  the  lateral  ventricle  is  drained.  Where  anom- 
alies of  the  ventricles  exist  they  most  frequently  involve  one  or  the 
other  of  the  horns.  Afterward,  moreover,  the  escaping  fluid  leaves 
the  brain  in  close  proximity  to  the  great  lymph  spaces  and  venous 
sinuses  at  its  base — a  fact  which  favors  its  rapid  absorption.  The 
right  side  of  the  brain  is  chosen  because,  if  any  irritation  of  the 
motor  areas  occurs,  the  left  side  of  the  body  is  involved,  and  more 
particularly  Broca's  speech  center  is  not  disturbed,  as  it  lies  in  the 
left  hemisphere.  The  approach  to  the  brain  is  easy;  the  brain 
need  not  be  handled,  and  is  but  slightly  injured  in  the  insertion 
of  the  drain." 

ACUTE  ANTERIOR  POLIOMYELITIS— INFANTILE  PARALYSIS 
In  poliomyelitis  we  meet  a  disease  by  which  we  are  singularly  handi- 
capped. Prophylaxis  amounts  to  nothing.  The  strong  and  the  well 
are  as  frequently  attacked  as  the  delicate — perhaps  more  frequently. 
Treatment. — During  the  acute  stage  of  the  involvement  of  the 
cord  our  efforts  count  for  httle.  We  order  that  the  child  be  kept  quiet 
in  bed,  that  a  laxative  be  given,  and  that  he  receive  light,  easily 
digested  nourishment,  and  then,  as  far  as  the  immediate  conditions 
are  concerned,  we  have  done  our  little,  but  our  all.  I  have  used 
the  bromids  and  ergot  and  the  iodids  internally,  and  ice-bags  and 


DIPHTHERITIC    PARALYSIS  379 

blisters  over  the  spine  at  the  site  of  the  lesion,  and  am  yet  to  be 
convinced  that  they  are  worthy  the  annoyance  which  they  cause 
the  patient  or  that  the  drugs  are  worth  the  indigestion  they  are 
apt  to  occasion.  That  the  disease  is  due  to  an  infection  is  probable, 
and  in  a  given  case  our  hope  must  be  that  the  infection  will  be 
mild  in  character.  The  degree  of  involvement  determines  the  re- 
sulting atrophy  and  loss  of  function. 

Later  Treatment. — From  ten  days  to  two  weeks  after  the  acute 
stage  has  passed  our  efforts  should  be  directed  toward  maintaining 
the  nutrition  of  the  affected  muscle  or  groups  of  muscles.  This  is  to 
be  done  by  mechanical  means,  electricity,  and  gymnastic  exercises 
(page  539). 

The  beneficial  action  of  electricity  consists  largely  in  exercising 
the  muscles  no  longer  under  voluntary  control,  and  thus  increasing 
their  circulation  and  nutrition.  The  immediate  object  of  the  elec- 
tricity is  to  induce  contraction  of  the  muscles.  Either  the  faradic 
or  the  galvanic  current  may  be  used.  The  faradic  should  first  be 
tried,  and  if  to  this  there  is  no  response,  the  galvanic  should  be 
used.  Sittings  of  from  five  to  fifteen  minutes  may  be  desirable, 
depending  somewhat  upon  the  age  of  the  child  and  the  age  and  ex- 
tent of  the  lesion.  The  longer  the  duration  of  the  disease,  the 
longer  should  be  the  sittings.  Once  daily  the  parts  should  be 
massaged  by  one  skilled  in  the  work.  When  this  is  not  available 
the  mother  or  nurse  may  undertake  with  some  advantage  the  sys- 
tematic manipulation  of  the  affected  muscles  by  kneading  and 
rubbing.  The  further  management  is  orthopedic,  and  consists  in 
the  prevention  of  deformities  by  the  use  of  splints  and  braces  and 
their  correction  by  tenotomies  and  tendon  transplantation. 

DIPHTHERITIC  PARALYSIS 

Every  child  with  diphtheria  should  be  watched  and  treated 
as  if  diphtheritic  paralysis  were  expected.  It  has  occurred,  to  some 
extent,  in  9  percent  of  my  cases.  The  first  sign  of  irregularity 
of  the  pulse  calls  for  an  enforced  recumbent  position  and  the  use 
of  strychnin.  If  marked  irregularity  of  the  heart  action  occurs 
early  in  an  attack  of  diphtheria,  myocarditis  may  be  suspected, 
a  condition  which  calls  for  as  active  measures  of  treatment  as  does 
the  irregularity  which  may  occur  later,  from  the  tenth  day  to  the 
third  week  of  convalescence,  which  usually  means  nerve  involve- 
ment.    The  two  conditions  may  occur  in  the  same  individual. 

The  soft  palate  and  the  muscles  of  deglutition  are  most  frequently 
involved.  There  may  be  paralysis  of  the  pharynx  and  larynx. 
Next  in  frequency  the  muscles  of  the  extremities  are  affected.  It 
has  been  my  experience  that  if  the  heart  is  to  be  attacked,  signs 
indicating  it  will  be  noticed  early — soon  after  the  paralysis  of  other 
parts  is  apparent — or  it  may  be  the  earliest  symptom,   the   first 


380  NERVOUS   DISORDERS 

warning  being  the  heart's  irregularity,  which  maybe  the  only  evidence 
of  its  involvement. 

Treatment. — If  after  ten  days  from  the  onset  of  throat  para- 
lysis, or  paralysis  elsewhere,  there  is  no  evidence  of  cardiac 
involvement,  it  will  be  unusual  for  it  to  develop  later,  although 
this  is  by  no  means  certain.  Should  it  occur,  absolute  rest  in  the 
recumbent  position  is  important.  The  patient  should  be  con- 
stantly under  the  eye  of  an  attendant.  He  must  not  be  allowed 
to  turn  over  in  bed  or  to  raise  his  head  without  assistance.  A 
hypodermic  syringe  loaded  with  j^q  grain  of  strychnin  and  o^^o  grain 
digitalin  should  be  in  constant  readiness.  Strychnin  should  be 
given  these  patients  throughout  the  entire  illness  and  well  on  into 
convalescence.  In  these  cases  we  rarely  have  to  deal  with  children 
under  eighteen  months  of  age,  my  youngest  case  of  diphtheritic 
paralysis  being  fifteen  months  old,  so  that  in  the  consideration  of 
doses  only  children  over  one  year  of  age  will  be  referred  to.  For 
a  child  from  one  to  two  years  old,  3^77  grain  of  strychnin  may  be 
given  at  three-hour  intervals;  from  two  to  four  years  of  age,  from 
lio"  to  Y^Q  grain  at  three-hour  intervals.  After  the  fourth  year, 
xio  to  Y^o^  grain  may  be  given  at  three-hour  intervals.  When  there 
is  marked  rapidity  of  the  heart's  action  with  irregularity  and  rest- 
lessness in  those  under  three  years  of  age,  from  one  to  two  drops 
of  tincture  of  strophanthus  may  be  given  with  yV  to  yV  grain  of 
codein,  and  repeated  at  two-hour  intervals.  After  this  age  one  and 
one-half  to  three  drops  may  be  given  with  to  to  |^  grain  of  codein 
at  two-hour  intervals.  The  codein  is  to  be  discontinued  as  soon  as 
the  restlessness  ceases.  For  those  in  whom  there  is  simply  paralysis 
of  the  muscles  of  deglutition  or  of  the  extremities,  small  doses  of 
strychnin  will  be  all  the  medication  required,  from  3^0^  to  o^^o  grain 
three  times  daily  being  sufficient.  Troublesome  features  in  the 
management  of  cases  in  which  there  is  marked  involvement  of  the 
palate,  the  pharynx,  and  the  larynx,  consist  in  the  difficulty  of 
feeding  the  patient  and  in  the  danger  of  aspirating  food  and  mucus 
as  a  result  of  the  paralysis.  The  tendency  of  diphtheritic  paralysis 
is  toward  recovery,  the  time  required  being  usually  from  four  to 
eight  weeks. 

Illustrative  Cases. — A  bov  six  years  of  age  had  a  very  mild  at- 
tack of  diphtheria,  not  of  sufficient  severity  to  necessitate  his  re- 
maining in  bed.  Two  weeks  after  the  attack,  the  time  of  his  coming 
under  my  care,  there  was  marked  paralysis  of  the  soft  palate  and 
pharynx  which  rendered  swallowing  most  difficult.  In  spite  of 
energetic  treatment  with  strychnin  hypodermatically,  the  paralysis 
soon  involved  the  larynx,  the  masseters,  and  the  muscles  of  all  the 
extremities.  Fortunately  the  heart  or  diaphragm  was  not  in- 
volved. There  was  a  constant  flow  of  saliva  which  at  times  entered 
the  trachea  unimpeded,  causing  severe  paroxysms  of  coughing.     In 


MULTIPLE   NEURITIS  38 1 

order  to  prevent  this,  the  legs  and  trunk  were  elevated,  the  head 
being  made  the  most  dependent  portion  of  the  body.  Swallowing 
was  impossible  and  he  was  given  by  gavage  every  six  hours  as 
indicated  completely  peptonized  milk,  whisky,  beaten  egg,  and 
strychnin.  The  boy  made  a  complete  recovery,  but  it  required 
three  months  to  accomplish  it.  In  another  patient,  fifteen  months 
of  age,  gavage  was  practised  at  six-hour  intervals  for  five  days, 
when  solids  could  be  swallowed. 

Gavage  (page  134)  is  but  little  objected  to  by  children  after  it  has 
been  used  once  or  twice.  It  should  be  employed  as  soon  as  it  is 
shown  that  enough  nourishment  cannot  be  taken  by  the  natural 
means.  If  coughing  results  in  attempts  at  swallowing,  it  means 
that  the  larynx  is  involved  and  that  feeding  by  the  usual  means 
should  not  be  attempted.  Nutrition  by  means  of  the  bow^el  may 
be  brought  into  use,  but  it  is  not  necessary  unless  there  is  cardiac 
paralysis,  in  which  event  the  resistance  of  the  patient  might  enter 
as  a  factor  making  gavage  dangerous.  Attempts  at  swallowing  may 
be  made  from  time  to  time.  Semisolid  substances,  such  as  scraped 
beef  and  soft-boiled  egg,  will  usually  be  better  managed  than  fluids, 
because  of  the  tendency  of  fluids  to  pass  through  the  glottis. 

MULTIPLE  NEURITIS 

Neuritis  of  this  nature,  aside  from  that  following  diphtheria, 
is  not  of  as  rare  occurrence  in  children  as  is  claimed  by  some 
authors. 

The  disease  may  be  due  to  various  toxic  agents  through  their 
specific  action  in  producing  an  acute  inflammation  and  degenera- 
tion of  the  peripheral  nerves.  Among  the  possible  causes  are 
malaria,  the  exanthemata,  grippe,  pneumonia,  and  typhoid  fever. 
Lead,  phosphorus,  arsenic,  and  alcohol  as  possible  causes  are  also 
to  be  kept  in  mind.  Lead  is  a  very  unusual  cause.  Arsenic,  phos- 
phorus, and  alcohol,  however,  are  used  extensively  as  therapeutic 
agents  during  child-life,  and  should  always  be  considered  as 
possible  etiologic  factors. 

I  recently  saw  two  pronounced  cases  in  two  brothers  following 
very  severe  scarlet  fever.  Many  mild  cases  of  neuritis  in  children, 
following  exhaustive  diseases  with  prolonged  toxemia,  are  doubtless 
overlooked,  the  prolonged  time  required  for  the  return  of  muscle  power 
in  the  arms  and  legs  after  such  diseases  being  attributed  solely  to 
muscle  weakness.  Sensory  disturbances  in  children  are  not  such 
prominent  symptoms  as  the  neurologist  would  have  us  believe,  for 
the  reason,  possibly,  that  he  usually  sees  only  the  more  severe 
cases.  The  mild  cases  seldom  come  under  his  care.  I  have  seen 
quite  a  number  of  the  mild  cases  in  which  there  were  sensory  dis- 
turbances and  a  diminished  patellar  reflex  following  lobar  pneumonia 
with  high  temperature,  and  also  after  severe  scarlet  fever. 


382  NERVOUS   DISORDERS 

Treatment. — The  management  is  largely  palliative,  there  being 
a  strong  tendency  to  spontaneous  recovery  in  from  four  to  eight 
weeks  from  the  onset.  Exciting  causes,  such  as  the  use  of  alcohol 
or  some  other  drug,  should,  of  course,  be  eUminated,  when  recovery 
usually  follows.  In  those  cases  due  to  the  toxemia  of  preceding 
disease,  time  and  good  care  are  usually  all  that  will  be  required  to 
effect  a  cure.  If  pain  is  present  the  best  means  of  relief  is  the  use 
of  heat,  the  affected  limb  being  bound  in  thick  layers  of  cotton- 
wool. The  salicylate  of  soda  and  iodid  of  potash  are  not  to  be  given 
to  young  children.  They  produce  no  appreciable  effect,  except 
possibly  a  disturbance  of  digestion  and  a  lessening  of  the  appetite. 
Should  the  pain  be  sufficient  to  interfere  with  sleep,  bromid  of  soda 
may  be  given  in  doses  of  from  eight  to  twelve  grains,  for  a  child  of 
from  five  to  ten  years  of  age,  at  bedtime  and  repeated  but  once. 
In  using  hypnotics  in  children,  one  drug  should  not  be  continued 
longer  than  three  days. 

Codein  is  a  satisfactory  sedative  for  a  child  in  case  the  bromid 
does  not  answer.  For  patients  from  five  to  ten  years  old,  from  one- 
tenth  to  one-sixth  grain  may  be  given  at  bedtime  and  repeated  once 
after  an  interval  of  three  hours. 

As  a  tonic  I  know  of  no  better  combination  of  drugs  for  a  child 
with  neuritis  than  the  following,  for  a  patient  from  five  to  ten  years 
of  age : 

I^.     Strychninse  sulphatis gr.  | 

Extracti  ferri  pomati gr   x 

Quininfe  bisulphatis 3j 

M.  et  ft.  capsulae  No.  xxx. 

Sig. — One  after  each  meal. 

If  constipation  is  present  or  should  result  from  the  administration 
of  iron,  from  one-third  to  one-half  grain  of  extract  of  cascara  may 
be  added  to  each  capsule.  The  capsules  are  given  for  ten  days, 
followed  by  cod-liver  oil  for  five  days.  The  oil  is  given  after  meals. 
At  the  end  of  five  days  the  tonic  capsules  are  repeated,  to  be  followed 
again  by  the  oil.  The  patient  should  have  the  benefit  of  an  outdoor 
life  as  early  as  possible.  Electricity  has  not  been  necessary  in  my 
cases,  neither  has  the  use  of  orthopedic  appHances  been  required. 
Massage  may  be  used  with  advantage  after  the  subsidence  of  the 
acute  symptoms.     It  should  be  given  by  one  skilled  in  the  work. 

FACIAL  PARALYSIS 

Paralysis  of  the  facial  nerve  is  not  of  infrequent  occurrence  in 
the  young.  It  may  result  from  forceps  pressure  at  birth  or  from 
pressure  exerted  by  the  bony  parts  of  the  pelvic  outlet.  In  later 
infancy  or  childhood  it  may  be  the  result  of  trauma  caused  by 
operative  manipvilations ;  it  may  be  of  rheumatic  origin;  it  may 
be  due  to  cerebellar  disease,  or  to  exposure  to  cold.     In  one  of 


CEREBRAL   PALSIES  383 

my  patients  it  was  attributed  to  sitting  by  an  open  window  in  a 
railroad  car  on  a  cold  day.  The  nerve  in  its  outward  passage  through 
the  fallopian  canal  may  become  diseased  from  the  presence  of  a 
purulent  otitis  media.  This  is  probably  the  most  frequent  cause 
of  the  paralysis. 

Treatment.  The  management  depends  entirely  upon  the  cause 
of  the  paralysis.  If  due  to  cerebral  disease,  but  little  is  to  be  ex- 
pected from  treatment.  If  due  to  an  otitis  media,  surgical,  pro- 
cedures, such  as  establishing  a  free  drainage  to  the  cavity  of  the 
middle  ear,  to  be  followed  by  frequent  hot  irrigations,  should  be  re- 
sorted to.  If  these  are  ineffective,  the  mastoid  should  be  opened  and 
the  cavity  drained  posteriorly.  Where  the  functional  activity  of  the 
nerve  is  delayed,  electricity  may  be  brought  into  use,  as  is  indicated 
below.  Cases  in  which  rheumatism  is  supposed  to  be  a  factor  should 
be  given  the  benefit  of  anti-rheumatic  treatment  by  the  use  of  the 
salicylates  (page  467).  If  the  case  is  due  to  cold  or  trauma  there  is 
a  strong  tendency  toward  recovery,  without  treatment.  It  is  diffi- 
cult to  judge  of  the  value  of  such  a  therapeutic  measure  as  elec- 
tricity; but  the  effect  of  exercising  the  paralyzed  muscles  and 
stimulating  nerve  conduction  by  its  use  must  be  of  some  service. 
If  the  electricity  is  used,  five-minute  daily  sittings  are  all  that  are 
necessary,  using  the  faradic  current  if  it  produces  sufficient  reaction. 
If  not,  the  interrupted  galvanic  current  should  be  employed. 

CEREBRAL  PALSIES 

Three  types  of  this  affection  are  recognized  by  neurologists, 
the  pre-natal,  the  birth,  and  the  post-natal. 

Concerning  the  etiology  of  the  pre-natal  cases,  considerable  con- 
fusion and  varying  opinions  exist.  Degeneracy  of  the  parents,  alco- 
holism, syphilis,  and  trauma  are  supposed  to  be  contributory  causes. 
I  have  seen  a  large  number  of  these  undoubtedly  pre-natal  cases, 
and  am  unable  to  add  anything  from  the  etiologic  standpoint.  In 
several  instances  the  patients  have  belonged  to  families  of  several 
children  each,  the  other  children  being  normal,  with  nothing  worthy 
of  note  in  the  family  history  and  with  a  normal,  uneventful  preg- 
nancy. 

Trauma  at  birth,  whether  due  to  the  use  of  forceps  or  to  com- 
pression of  the  head  in  a  prolonged  or  abnormal  delivery,  may  result 
in  meningeal  hemorrhages  causing  an  immense  number  of  cases 
of  cerebral  palsy.  The  obstetrician  should  always  keep  in  mind 
that  with  him  rests  the  possibility  of  making  a  hopeless  invalid 
or  an  idiot  of  the  child  he  is  about  to  deliver.  It  is  fully  appre- 
ciated that  under  unusual  conditions  in  obstetric  practice  certain 
risks  of  head  injury  must  be  taken  for  the  sake  of  the  immediate 
demands  of  the  mother  or  the  child,  but  the  large  number  of  cases 
of  cerebral  palsy  and  idiocy    which   I   have   seen   have   impressed 


384  NERVOUS   DISORDERS 

upon  me  the  necessity  of  treating  the  child's  head  during  delivery 
with  the  utmost  care. 

The  pre-natal  and  birth  palsies  are  often  paraplegias  or  diplegias, 
and  as  such  show  a  wide  distribution  of  the  lesions.  In  the  post- 
natal or  the  acquired  cases  there  is  more  apt  to  be  a  hemiplegia,  the 
hemorrhages  usually  resulting  either  from  blows,  falls,  convulsions, 
or  infectious  processes.  A  comparatively  trifling  injury  is  some- 
times sufficient  to  produce  a  hemorrhage. 

Illustrative  Cases. — A  five-year-old  boy,  a  pronounced  hemi- 
plegic  with  normal  mentality,  owes  his  present  condition  to  a  fall 
from  his  baby-carriage  to  the  ground  when  nine  months  of  age. 
The  fall  was  followed  by  repeated  convulsions  and  hemiplegia. 
He  came  under  my  care  a  few  days  after  the  fall.  The  clot  was 
located,  the  skull  trephined,  the  blood-clot  removed,  and  the  bleed- 
ing vessel  ligated.  The  boy  today  walks  well  with  a  brace  and 
will  be  able  to  discard  it  in  a  few  years;  the  arm  will  probably 
never  be  of  much  service. 

Another  child,  fourteen  months  of  age,  was  perfectly  normal  pre- 
vious to  an  acute  attack  of  indigestion  with  high  fever  and  con- 
vulsions. The  seizures  were  repeated  several  times  during  the  day. 
After  the  third  convulsion,  it  was  noticed  that  there  was  complete 
paralysis  of  the  left  side  of  the  face  and  of  the  right  arm  and  leg. 
The  child  died  thirteen  months  afterward.  His  mental  condition 
never  cleared — he  remained  an  idiot  until  death. 

Treatment. — The  medical  treatment  of  these  cases  of  paralysis 
consists  in  maintaining  a  high  degree  of  nutrition.  Drugs  are  of  no 
service.  The  management  in  general  in  the  different  types  of  cases 
varies,  depending  upon  the  intelligence  of  the  patient,  the  location 
and  extent  of  the  paralysis,  and  the  resulting  deformity.  Braces  are 
necessary  in  many  cases  to  prevent  contractions  and  deformities 
or  to  aid  in  correcting  those  already  present.  In  some  of  my  cases 
of  normal  or  fair  mentality  marked  improvement  has  followed 
daily  systematic  manipulations  and  exercises  (page  539)  under  the 
management  of  an  expert  in  this  line  of  work. 

A  description  of  operative  measures  and  a  discussion  of  the 
cases  in  which  they  are  applicable  m.ay  be  found  in  all  works  on 
orthopedics.  Systematic  exerc'se,  massage,  and  training  in  the 
use  of  the  limbs  should  be  the  later  management  of  all  operative 
cases,  in  order  that  the  patients  may  derive  the  full  benefit  from 
the  operation. 

IDIOCY 

Generally  speaking,  there  are  two  varieties  of  idiocy — the  pre- 
natal and  the  acquired.  There  is  a  very  close  association  between 
idiocy  and  cerebral  palsy.  Not  all  idiots  suffer  from  paralysis, 
neither  are  all  cases  of  cerebral  palsy  idiots;  in  the  majority  of 
the  cases,  however,  when  either  is  present,  the  other  will  be  found 


IDIOCY  385 

associated  in  a  greater  or  less  degree-  sometimes  the  mental,  some- 
times the  physical,  infirmity  predominating. 

The  degree  of  mental  impairment  varies  considerably,  being  de- 
pendent upon  the  location  and  severity  of  the  brain  lesion,  and 
whether  it  is  a  sclerosis,  porencephalus,  atrophy,  or  is  due  to  a  lack 
of  development.  There  are  cases  in  which  there  is  scarcely  sufficient 
cerebration  for  the  patient  to  recognize  his  parents,  and  others  in 
whom  it  is  difficult  to  determine  whether  they  are  within  or  without 
the  border-land  which  we  have  come  to  regard  as  normal.  The 
diagnosis  in  most  cases  can  be  made  at  a  glance.  In  two  of  the 
types,  both  pre-natal,  the  INIongolian  idiot  and  the  cretin,  some  con- 
fusion may  exist  in  differentiation.  The  latter  will  be  discussed 
separately  in  another  section. 

Treatment.  The  management  of  idiocy  is  to  be  considered  from 
two  standpoints:  First,  as  to  the  physical  condition.  Under  this 
heading  is  included  the  correction  of  deformities  and  the  management 
as  to  hygiene  and  nutrition.  The  latter,  of  course,  should  be  the 
best  obtainable  in  any  given  case.  The  other  consideration  rests  en- 
tirely upon  the  mental  aspect  of  the  case  and  concerns  not  only  the 
patient  but  the  family  and  their  immediate  interests.  It  may  be  said 
that,  without  exception,  the  place  for  a  mentally  defective  child  is  in 
an  institution  which  is  devoted  to  the  care  and  teaching  of  such  chil- 
dren. He  should  be  placed  where  much  will  not  be  expected,  where 
he  will  be  associated  with  others  of  his  kind,  where  his  work  and  his 
play  are  adjusted  and  presided  over  by  educated  men  and  women 
who  have  made  such  conditions  the  study  of  their  lives.  The  idiot 
has  rights.  He  has  a  right  to  live  out"  his  unfortunate  life  in  as 
pleasant  a  manner  as  possible,  and  this  is  better  accomplished  in 
an  institution  than  in  any  individual  home.  Here,  among  other 
things,  he  is  taught,  according  to  his  capacity  to  learn,  useful  occu- 
pations, and  not  a  few  thus  taught  become  self-supporting.  At 
rare  intervals  one  is  found  who  possesses  remarkable  mental  traits 
along  certain  Unes,  traits  which  the  average  normal  individual  is  in- 
capable of  understanding.  I  have  one  such  case  under  my  care. 
Cases  showing  a  moderate  degree  of  infirmity  often  become  skilled 
in  handicraft.  They  execute  mechanically  with  surprising  accu- 
racy. There  have  been  great  geniuses  of  the  past  who  in  some 
respects  were  not  considered  mentally  normal  by  their  contempora- 
ries. 

It  is  impossible  to  form  even  a  fair  estimate  as  to  how  the  men- 
tally defective  child  will  develop,  with  age  and  suitable  instruction 
from  those  who  are  best  able  to  discover  his  possibilities.  The 
placing  of  these  children  in  public  institutions  is  often  strenuously 
objected  to  on  sentimental  grounds  by  the  poorer  elements  of  society 
because  of  their  fears  and  prejudices  against  such  institutions,  and 
in  consequence  the  child  is  kept  at  home,  greatly  to  his  detriment 


386  NERVOUS   DISORDERS 

and  to  the  decided  injury  of  other  children  in  the  family.  Time 
and  again  I  have  pleaded  with  the  mothers  and  fathers  of  such 
children  without  avail.  Few  villages  throughout  the  country  do 
not  have  an  idiot  or  an  idiotic  epileptic  for  school-bovs  to  taunt 
and  for  school-girls  to  fear.  Most  pitiable  objects  are  these  human 
derelicts,  with  whom  the  State  does  not  interfere  because  they  are 
"harmless."  The  prejudices  of  parents  are  largely  due  to  the  spas- 
modic attacks  of  virtue  of  the  so-called  "yellow"  press,  which  peri- 
odically writes  up,  often  with  illustrations,  under  glaring  headlines, 
the  abuses  in  this  or  that  public  institution,  all  of  which  is  solely 
in  the  interest  of  their  circulation.  Sooner  or  later,  if  he  lives,  the 
idiot  of  poor  parentage  will  become  a  public  charge,  and  the  better 
his  condition  at  the  time,  the  happier  he  will  be. 

Parents  of  means  and  intelligence  will  usually  place  such  a  child  in 
one  of  the  many  private  institutions  that  are  conducted  for  the  care 
of  defectives;  but  the  objection  will  often  be  raised,  even  by  these 
people,  that  in  such  children  there  is  so  little  mentality  that  teach- 
ing is  useless.  This  may  be  true,  but  if  for  no  other  reason,  the 
child  should  be  removed  from  the  home  because  of  his  invariably 
pernicious  influence  on  other  members  of  the  family.  The  vicious, 
the  unclean,  and  those  showing  marked  moral  degeneracy  should  be 
placed  in  institutions  as  soon  after  the  fourth  year  as  possible.  If 
they  are  to  be  a  public  charge,  they  should  be  removed  from  the 
home  as  soon  as  they  arrive  at  the  age  Umit  which  the  rules  of 
the  institution  require  for  admission.  If  the  patient  is  tractable, 
he  may  remain  at  home  until  the  sixth  or  seventh  year,  particu- 
larly if  there  are  no  other  children  in  the  family.  In  the  event 
of  younger  children  whose  natural  tendencies  and  powers  of  imita- 
tion are  always  strong,  the  defective  child  should  be  removed  as 
early  as  possible. 

ERB'S  PALSY— OBSTETRIC  PARALYSIS 
This  paralysis  is  due  to  an  injury  of  the  brachial  plexus  during 
labor.  There  is  little  or  no  power  in  the  muscles  supplied  by  that 
portion  of  the  plexus  which  is  the  seat  of  the  injury.  The  arm 
hangs  limp  by  the  side.  The  tendency  of  these  cases,  whether  in- 
volving the  upper  or  the  lower  arm,  is  toward  recovery  unless  the 
nerve  lesion  is  a  very  grave  one. 

Treatment. — The  atrophy  and  contractions  which  develop  are  de- 
termined largely  by  the  extent  of  the  injury  and  to  a  lesser  degree 
by  the  treatment.  During  the  first  three  weeks  in  hfting  and  hand- 
ling the  infant  the  arm  should  be  protected  from  other  injuries  such 
as  may  take  place  in  bathing  and  the  other  manipulations  necessary 
in  the  care  of  a  baby.  After  this  time,  massage  of  the  entire  arm 
and  shoulder  with  lanolin  should  be  practised  at  least  twice  a  day, 
from  ten  to  fifteen  minutes  at  a  time.     After  two  weeks,  electricity 


ANGIONEUROTIC   EDEMA  387 

may  be  used  for  a  few  minutes  each  day.  If  the  child  can  bear  it, 
the  faradic  current  answers  best.  But  in  case  there  is  no  response  to 
faradism,  the  galvanic  current  should  be  used.  Under  massage  and 
electricity,  the  improvement  in  the  arm  is  often  most  satisfactory. 
It  is  not  well,  however,  to  promise  the  parents  that  a  normal  arm 
will  be  the  outcome.  I  have  seen  cases  in  which  there  was  almost 
complete  restoration  of  power  after  it  had  been  entirely  lost,  while 
in  others  the  arm  was  permanently  disabled.  The  degree  of  im- 
provement is  dependent  upon  several  factors,  the  chief  one  of  which — 
the  extent  of  the  nerve  injury — is  in  every  case  uncertain.  Opera- 
tive measures  consisting  of  grafting  and  transplanting  of  the  nerve 
have  been  advocated  recently  by  many  surgeons.  I  have  had  no 
experience  along  this  Hne.  It  would  seem  to  be  worthy  of  trial 
when  it  is  demonstrated  that  the  case  has  made  all  the  improvement 
that  it  would  be  likely  to  make  with  other  treatment. 

HICCOUGH 
Hiccough  is  a  spasm  of  the  diaphragm,  usually  due  to  gastric 
irritation  from  the  distention  of  the  stomach  or  intestine  with  gas 
or  overloading  of  the  stomach  with  food.  Under  such  conditions 
it  is  usually  of  little  consequence,  and  may  readily  be  relieved,  if 
the  attack  is  prolonged,  by  an  enema  of  soap-water  and  a  laxative 
dose  of  rhubarb  and  soda.  When  it  occurs  with  any  grave  illness, 
it  is  a  symptom  of  serious  import.  Hysterical  girls  will  often  have 
hiccough  to  quite  an  alarming  degree.  The  attack  usually  follows  a 
period  of  unusual  excitement.  In  these  patients,  from  twenty  to 
thirty  grains  of  bromid  of  soda  repeated  in  from  twenty  to  thirty 
minutes  will  usually  control  the  spasm. 

ANGIONEUROTIC  EDEMA 
Angioneurotic  edema  is  sometimes  referred  to  as  "giant  hives." 
When  it  occurs  in  young  children,  it  is  most  apt  to  involve  the  tongue 
and  hps.  When  involving  the  soft  parts,  the  urticarial  lesions 
often  produce  an  immense  amount  of  swelling.  This  is  particularly 
apt  to  be  the  case  when  the  tongue  and  lips  are  affected.  I  have 
seen  the  Ups  swollen  to  several  times  their  normal  thickness.  In 
the  case  of  a  boy  four  years  of  age,  the  tongue  and  lower  lip  were 
tremendously  swollen.  Speaking  was  impossible  and  swallowing 
difficult.  It  was  supposed  that  he  had  been  given  carbolic  acid 
or  some  corrosive  poison.  These  cases  usually  develop  suddenly 
and  are  apt  to  occasion  great  alarm.  In  the  case  referred  to,  I 
was  called  thirty  miles  into  the  country  to  see  the  child  in  consulta- 
tion. Cases  have  been  reported  in  which  the  swelling  of  the  tongue 
was  suflticient  to  produce  suffocation,  necessitating  incision  into  the 
tongue  to  reduce  the  swelling.  The  cases  I  have  seen  have  always 
been    associated    with   gastro-enteric    disturbances.      The    swelling 


388  NERVOUS   DISORDERS 

usually  disappears  very  rapidly,  although  not  quite  as  rapidly  as  it 
develops.  At  the  end  of  twenty-four  hours  but  a  slight  enlargement 
ordinarily  remains. 

The  treatment  of  this  form  of  urticaria  is  the  same  as  that  of 
urticaria  in  general.  The  intestinal  canal  should  be  kept  purged 
with  saline  laxatives  and  the  patient  put  on  a  barley  and  broth 
diet  for  two  or  three  days  to  relieve  the  intestinal  tract. 

For  local  purposes,  where  the  mucous  membrane  alone  is  involved, 
a  two  percent  solution  of  sodium  biborate  in  water,  applied  on 
pieces  of  old  linen,  has  given  the  best  results.  This  may  be  con- 
tinued until  the  swelling  becomes  greatly  reduced  or  entirely  dis- 
appears. 


SYPHILIS 

PRIMARY  CONGENITAL  SYPHILIS 
Treatment. — The  only  means  of  treating  congenital  syphilis  in 
infants  is  by  the  use  of  mercury,  either  locally,  as  by  inunctions, 
by  internal  administration,  or  hypodermatically.  The  hypodermic 
use  of  the  mercurial  preparations,  such  as  the  albuminate  or  the 
salicylate,  are,  for  obvious  reasons,  not  to  be  advised  in  voung 
children.  The  use  of  the  needle  would  have  the  effect  of  sending 
the  patient  to  others  for  treatment,  particularly  if  the  case  were 
seen  in  out-patient  practice.  The  use  of  the  mercurial  ointment 
by  inunction  is  a  satisfactory  method  in  hospitals  and  in  children's 
institutions,  where  a  nurse  can  make  the  necessary  applications; 
in  private,  however,  it  is  objectionable  because  of  the  inunction  itself, 
which  may  cause  comment,  and  because  of  the  staining  of  the  skin. 
In  fact,  this  treatment  cannot  well  be  carried  on  without  other 
members  of  the  family  becoming  acquainted  with  the  nature  of  the 
illness.  Definite  rules  for  the  management,  as  regards  kissing 
and  the  care  of  feeding  utensils,  should  be  given,  so  that  the  other 
members  of  the  family  may  be  protected  and  the  real  condition 
remain  unknown.  Among  the  poorer  class  and  in  out-patient  work 
I  have  found  the  inunction  method  unsatisfactory,  for  the  additional 
reason  that  its  use  is  not  continued  sufficiently,  and  it  is  very  apt 
to  be  indifferently  done.  It  is  often  postponed  and  forgotten, 
and  as  the  disease  permits  of  no  temporizing,  it  is  for  the  interest 
of  the  patient  that  the  most  effective  means  possible  for  its  con- 
trol be  brought  into  use  at  the  earliest  possible  moment,  and  that 
is  by  internal  administration. 

If  the  inunction  is  employed,  the  mercurial  ointment,  U.  S.  P., 
should  be  used,  ten  grains  being  rubbed  into  the  skin  daily.  The 
rubbing  should  be  continued  about  ten  minutes,  as  this  time  will 
be  required  for  the  ointment  to  be  thoroughly  rubbed  in.  The  use 
of  mercury  internally  gives  the  best  results  among  all  classes.  It 
is  my  observation,  after  the  treatment  of  several  hundred  of 
these  cases,  that  the  bichlorid  of  mercurv  in  small,  frequently  re- 
peated doses  is  the  best  medication.  It  is  given  in  tablet  form. 
Its  use  will  have  to  be  continued  for  a  long  time,  and,  as  people 
are  fond  of  giving  drugs,  we  cater  to  the  weak  side  of  human  na- 
ture, and  thus  do  the  greatest  good  to  our  patient. 

Mercury — The  Dosage  and  Method  of  Administration. — For  all 
infants  under  one  year  of  age  the  scheme  of  medication  is  the  same, 

389 


390  SYPHILIS 

and  this  one  covers  the  great  majority  of  our  cases.  Usually  they  are 
seen  before  the  third  month.  I  order  the  tablet  triturate  of  bi- 
chlorid  of  mercury,  ^^q  grain.  The  mother  is  instructed  to  give 
two  tablets  daily,  morning  and  night,  after  feeding.  She  is  told 
to  give  on  alternate  days  an  additional  tablet,  after  feeding,  until 
live  are  given  daily  or  until  the  mercury  produces  loose  green 
stools.  It  is  comparatively  rare  that  an  infant  of  the  tenderest 
age  cannot  take  4V  grain  daily  without  inconvenience.  If  green 
stools  with  a  watery  tendency  result,  the  increase  is  temporarily 
withheld.  It  is  very  rare  that  the  above  amount  will  not  ultimately 
be  taken  without  inconvenience.  Further,  the  dosage  of  from 
4V  to  ^V  grain  in  twenty-four  hours,  in  the  great  majority  of  the 
cases,  is  all  that  is  necessary  to  control  the  disease.  If  an  improve- 
ment does  not  take  place  after  a  week's  administration,  in  the  ab- 
sence of  intestinal  symptoms,  the  amount  may  be  increased  to  2V 
grain  in  twenty-four  hours. 

If,  after  the  administration  four  or  five  times  daily  of  the  bi- 
■chlorid  in  the  small  doses  of  2^^o  grain  has  been  continued  for 
several  days,  improvement  does  not  take  place  because  of  failure 
on  the  part  of  the  child  to  absorb  the  drug,  inunctions  may  be  used 
in  addition  to  the  internal  treatment.  They  have  been  needed, 
however,  in  but  few  of  my  cases. 

Convalescence. — In  a  typical  case  the  first  sign  that  the  child  is 
improving  will  be  the  fading  of  the  rash.  It  disappears  gradu- 
ally, leaving  the  characteristic  staining  of  the  skin,  which  also  clears 
up  in  a  few  weeks.  Coincident  with  the  fading  of  the  rash,  the  coryza 
becomes  less  pronounced  and  the  hoarse  voice  becomes  clearer.  If 
there  has  been  an  enlargement  of  the  liver  and  spleen,  after  a  few 
weeks  of  treatment,  they  will  be  noticed  to  have  diminished  in  size. 
The  child  gains  in  weight,  and  if  the  case  progresses  satisfactorily, 
soon  looks  like  a  normal  baby.  This  is  not  always  the  happy  out- 
come, however.  Occasionally  we  have  cases  which  apply  for  treat- 
ment with  the  vital  powers  greatly  depressed  or  wath  so  intense  an 
infection  that  treatment  is  of  no  avail,  and  they  die  in  a  few  wrecks 
from  marasmus. 

The  enlargement  of  the  epitrochlear  glands  is,  in  my  experience, 
the  last  sign  to  disappear,  and  in  many  cases  these  glands,  though 
reduced  in  size,  always  remain  enlarged  without  any  other  persis- 
tent evidence  of  the  disease. 

Later  Treatment. — What  should  be  the  further  management 
of  such  a  so-called  "cured  "  case?  Are  we  justified  in  discharging 
the  patient  and  allowing  him  to  pass  from  under  our  observation? 
My  experience  proves  the  contrary,  nor  can  I  state  that  congenital 
syphilis  is  ever  cured.  I  have  seen  many  cases,  how^ever,  that  were 
apparently  cured,  and  which  showed  no  signs  whatsoever  of  the 
disease.     Against  my  advice,  they  have  passed  from  under  observa- 


TARDY    HEREDITARY   SYPHII^IS  39I 

tion  for  two,  three,  or  four  years,  and  then  reappeared  for  treatment 
because  of  the  presentation  of  some  manifestation  of  a  tertiary 
lesion — a  so-called  "tardy  hereditary  syphilis." 

My  instructions  to  the  parents  or  guardians  of  my  syphiUtic 
patients  apparently  cured,  are  to  bring  them  to  me  once  in  three 
months  for  examination.  If  they  remove  to  such  a  distance  that 
this  is  not  possible,  then  I  ask  them  to  take  the  child  at  the  speci- 
fied time  to  some  other  physician  and  explain  to  him  the  nature 
of  the  previous  illness.  For  such  patients  as  return,  for  the  first 
two  or  three  years,  I  often  advise  a  course  of  bichlorid  for  one 
month  out  of  every  three.  I  do  not  feel  that  it  is  necessary  for  such 
a  child  to  show  positive  specific  signs  in  order  to  receive  this  inter- 
rupted treatment ;  if  he  shows  retarded  growth  or  anemia  or  a  his- 
tory is  given  of  his  lack  of  resistance  to  disease  he  should  unquestion- 
ably have  the  advantage  of  the  treatment.  In  such  a  case  I  find 
that  the  improvement  is  much  more  satisfactory  when  some  prepa- 
ration of  mercury  is  used  to  supplement  whatever  restorative  treat- 
ment may  be  suggested. 

TARDY  HEREDITARY  SYPHILIS 

By  tardy  hereditary  syphilis  it  is  understood  that,  for  some 
reason,  the  infection  failed  to  manifest  its  presence  with  any  appre- 
ciable severity  until  the  period  of  childhood  was  reached. 

In  its  selection  of  anatomic  sites  for  its  development,  and  in 
the  nature  of  the  lesion,  it  closely  resembles  the  tertiary  form  in 
the  adult.  The  eyes,  the  bones,  and  the  nervous  system  are  par- 
ticularly apt  to  be  involved.  The  development  of  the  Hutchinson 
teeth  and  the  involvement  of  the  shafts  of  the  long  bones,  resulting 
in  a  periostitis,  are  its  most  frequent  manifestations,  these  together 
with  general  malnutrition,  are  almost  always  associated  with  the 
disease  in  childhood. 

Treatment. — As  in  the  treatment  of  tertiary  syphiUs  in  the  adult, 
so  likewise  in  the  treatment  of  the  late  hereditary  form  in  children, 
the  iodids  play  an  important  part.  Much  better  results,  however,  are 
obtained  with  the  so-called  "mixed  treatment."  The  iodids  alone 
are  not  sufficient  to  give  us  our  best  results,  and  the  results  wath 
mercury  alone  are  not  so  prompt  and  satisfactory  as  when  the  two 
drugs  are  combined.  For  an  average  case  of  periostitis  involving 
the  anterior  portion  of  the  tibia  in  a  child  four  years  of  age,  from 
gig-  to  2V  grain  of  bichlorid  of  mercury  should  be  given  daily,  com- 
bined with  sufficient  iodid  of  potash  to  produce  the  characteristic 
coryza.  This  may  necessitate  the  giving  of  from  twelve  to  twenty 
grains  daily,  as  children  vary  greatly  in  their  susceptibility  to  the 
drug.  The  mercury  and  the  iodid  of  potash  should  not  be  given 
in  one  mixture,  as  the  combination  is  most  disagreeable  to  the  taste. 
It  is  far  better  to  give  the  bichlorid  in  the  form  of  tablet  triturates. 


392  SYPHILIS 

The  iodid  of  potash  is  best  given  in  a  saturated  solution,  one  drop 
of  which  represents  one  grain  of  the  drug.  This  is  best  taken  when 
dropped  into  milk  after  meals.  Beneficial  results  from  the  treat- 
ment will  usually  be  apparent  in  a  few  days.  If  there  is  a  periostitis, 
the  pain  will  be  the  first  symptom  to  disappear. 

The  administration  of  the  iodid  of  potash  should  always  be 
interrupted,  chiefly  because  of  its  possibilities  of  deranging  the 
child's  digestion.  I  usually  give  it  for  ten  days,  followed  by  a  rest 
of  five  days,  when  it  is  again  resumed.  Proper  nutrition  in  these 
cases  is  a  most  important  factor  in  their  management.  If  the 
iodid  is  given  to  the  point  of  tolerance,  its  omission  for  a  few  days 
will  not  be  noticed.  The  mercury  is  given  for  weeks  continuously  in 
doses  of  from  -^^  to  ^V  grain  three  times  a  day,  graduated  according 
to  the  age.  Later,  when  the  progress  of  the  case  shows  that  the 
disease  is  under  control,  the  two  drugs  should  be  given  alternately, 
for  ten  days  each.  How  long  this  treatment  should  be  continued 
must  be  determined  by  each  individual  case.  Cases  which  are 
apparently  cured  should  be  instructed  to  report  to  the  physician 
every  three  months.  I  frequently  advise  a  course  of  treatment  for 
three  or  four  weeks,  two  or  three  times  a  year.  A  sufficient  excuse 
for  such  action  may  be  the  condition  of  the  child,  who  may  show 
a  tendency  toward  slow  growth  and  improper  nutrition.  The  pa- 
tient should  be  kept  under  observation  for  years.  He  should  be 
seen  at  stated  intervals  until  the  adult  period  is  reached,  when  the 
nature  of  the  trouble  should  be  explained  to  him.  The  disease  from 
which  the  child  is  suffering  should  always  be  made  plain  to  parents, 
or  at  least  to  one  of  them,  in  order  that  the  patient  may  not  be 
allowed  to  pass  from  under  medical  observation  in  ignorance  of  his 
true  condition. 

TARDY  MALNUTRITION  OF  SYPHILITIC  ORIGIN 
The  possible  manifestations  of  syphilis  in  the  young,  as  in  the 
adult,  are  many.  In  children,  not  the  least  interesting  and  impor- 
tant are  the  cases  in  which  late  malnutrition  is  the  only  evidence 
of  the  syphilitic  infection.  The  patients  are  usually  thin,  some- 
times sallow,  sometimes  pale,  with  little  or  no  adipose  tissue.  They 
are  almost  always  undersized,  as  regards  height,  always  under- 
weight, the  appetite  is  poor,  and  they  have  but  little  endurance 
and  correspondingly  little  resistance.  The  cases  seen  by  me  were 
between  three  and  ten  years  of  age.  When  two  such  children  are 
seen  in  a  family,  in  which  both  parents  are  robust,  it  is  a  strong 
indication  that  they  are  suffering  from  the  results  of  a  remote  syphi- 
litic infection  in  one  of  the  parents.  The  physical  examination 
may  prove  nothing  definitely. 

Cases  of  late  malnutrition,  non-syphihtic  in  character,  due  to 
poor  hvgiene  and  faulty  feeding,  may  present  symptoms  identical 


TARDY    MALNUTRITION    OF    SYPHILITIC    ORIGIN  393 

with  the  above,  so  that  while  the  two  conditions  cannot  be  differ- 
entiated by  the  cUnical  signs,  there  may  be  sufficient  grounds  for 
suspicion  to  warrant  us  in  questioning  the  father,  when  the  history  of 
a  primary  sore  with  perhaps  secondary  lesions  may  be  elicited. 
There  may  have  been  prolonged  treatment  with  a  subsidence  of  all 
the  symptoms,  and  the  patient  may  have  been  pronounced  cured 
and  told  that  it  was  safe  to  marry.  Many  times  have  I  heard  this 
story  when  the  evidence  of  transmission  was  before  me  in  the  form 
of  a  typical  case  of  congenital  syphilis. 

Treatment. — Treatment  of  tardy  malnutrition  of  syphiUtic  origin 
by  the  supportive  and  restorative  methods  used  in  the  non-syphilitic 
malnutrition  cases  is  without  avail.  (See  Tardy  Malnutrition,  page 
158.)  These  patients  require  mercury  either  alone  or  combined 
with  the  iodids.  To  the  usual  methods  of  treatment  with  iron, 
cod-Uver  oil,  baths,  and  massage,  there  will  be  but  httle  response, 
but  add  bichlorid  of  mercury  or  the  iodid  of  potash  and  the  case 
improves,  slowly  to  be  sure,  but  the  improvement  is  invariable. 
In  the  management  of  such  a  case  the  child  should  be  given  the 
advantage  of  an  outdoor  life  with  free  ventilation  of  the  sleeping- 
room  at  night.  The  food  should  be  highly  nutritious,  containing 
a  large  amount  of  proteid.  Eggs,  meat,  milk,  and  the  high-proteid 
cereals,  such  as  oatmeal,  are  the  most  valuable.  The  dried  legumes, 
— peas,  beans,  and  lentils, — given  in  the  form  of  purees,  are  a  valu- 
able addition  to  the  diet.  Salt  baths  at  bedtime  (page  31)  during 
the  entire  year,  followed  by  oil  inunctions  during  the  cooler  months, 
are  valuable  in  restoring  the  child  to  a  vigorous  condition.  As 
these  children  are  almost  always  anemic,  it  may  be  well  to  combine 
the  bichlorid  of  mercury  with  nux  vomica  and  quinin.  For  a  child 
from  five  to  ten  years  of  age,  the  following  prescription  has  been 
used  with  marked  benefit : 

I^.     Hydrargyri  bichloridi gr.  ss 

Tincturae  nucis  vomicae gtt.  xc 

Extracti  ferri  pomati gr.  x 

Quininae  bisulphatis 5j 

M.  div.  et  ft.  capsulae  No.  xxx. 

Sig. — One  capsule  after  each  meal. 

This  is  given  for  ten  days,  alternating  with  bichlorid  of  mercury 
in  tablet  form — gV  grain  three  times  daily  after  meals.  During 
the  ten  days  when  the  bichlorid  is  given  alone,  maltine  and  cod- 
liver  oil  may  be  given — one  dessertspoonful  three  times  a  day  after 
meals.  Every  ten  days  the  medication  other  than  the  bichlorid 
is  changed.  The  latter  should  be  given  continuously.  In  these 
cases,  iodid  of  potash  is  not  to  be  given  early  in  the  treatment, 
for  the  reason  that  the  appetite  is  usually  poor  or  indifferent,  and  the 
administration  of  the  drug  at  this  time  might  further  decrease  the 
desire  for  food.     The  iodid  of  iron  may  be  used  in  doses  of  from 


394  SYPHILIS 

ten  to  fifteen  drops,  three  times  daily,  should  the  physician  desire 
to  change  the  form  in  which  the  iron  is  administered. 

Prolonged  treatment  will  usually  be  required.  These  cases 
should  be  kept  under  close  observation  for  at  least  two  years,  or 
until  they  arrive  at  adolescence,  when  they  should  be  made  ac- 
quainted with  the  nature  of  the  disease.  During  the  entire  growing 
period  the  administration  of  mercury  during  one  month  out  of  every 
three,  or  possibly  every  six,  depending  upon  the  child's  condition, 
will  insure  better  growth  and  a  more  vigorous  development  both 
physically  and  mentally. 


DEFORMITIES 

INGUINAL  HERNIA 

Inguinal  hernia  is  of  rare  occurrence  in  girls  but  comparatively 
frequent  in  boys.  Predisposing  causes,  other  than  the  anatomic, 
are  whooping-cough  and  colic.  I  have  seen  several  cases  due  to 
each  of  these  conditions.  In  a  like  manner,  constipation  or  difficult 
micturition  may  be  a  cause. 

Reduction.  — The  reduction  of  an  inguinal  hernia  in  an  infant 
may  be  difficult  because  of  the  distended  abdomen  and  the  abdom- 
inal pressure  exerted  by  crying.  It  is  best  accomplished  while  the 
child,  with  legs  and  buttocks  considerably  elevated,  is  held  by 
an  attendant.  Gentle  manipulation  with  the  thumb,  index  and 
second  finger,  which  grasp  the  lower  portion  of  the  tumor,  and 
pressure  toward  the  ring,  are  usually  successful.  If  reduction  is 
not  readilv  effected,  it  is  better  to  anesthetize  the  child,  after  which 
it  can  usually  be  done  with  comparative  ease. 

Treatment. — The  treatment  of  inguinal  hernia  in  infants  and 
young  children  is  by  mechanical  means  or  by  operation.  In  in- 
fants under  one  year  of  age  operation  is  rarely  required.  The 
most  satisfactory  measure  in  my  hands  for  treating  inguinal  hernia 
has  been  by  the  use  of  a  hard-rubber,  cross-body  truss.  The  pad 
should  be  but  slightly  convex.  A  hard-rubber  truss  is  readily 
cleaned,  and  the  cross-body  truss  keeps  its  position  in  young  infants 
better  than  does  any  other.  If  there  is  a  double  hernia,  the  hard- 
rubber  truss  or  the  Hood  frame  truss,  made  of  hard  rubber,  may 
be  used.  Measurement  for  the  truss  is  taken  around  the  hips  on 
a  plane  with  the  hernia.  The  child  should  wear  the  truss  day  and 
night.  By  placing  the  truss  in  hot  water  for  a  few  seconds  or  warming 
it  slightly  before  the  fire,  it  can  readily  be  bent  so  as  to  fit  the  patient 
comfortably.  When  the  truss  is  removed  for  the  purpose  of  cleansing, 
which  should  be  done  twice  a  day,  a  helper  should  be  at  hand  to 
support  the  ring  so  that  there  shall  be  no  descent  of  the  hernia. 
One  descent  may  mean  that  several  weeks'  care  has  been  brought 
to  naught.  It  is  well  to  keep  the  skin  under  the  truss  well  pow- 
dered when  first  applied,  and  the  child  is  often  made  more  com- 
fortable by  placing  absorbent  cotton  between  the  skin  and  the  hard 
rubber. 

As  the  child  grows,  the  truss  will  have  to  be  changed  frequently. 
Its  use  should  be  continued  for  at  least  one  year  after  the  last  descent 
of   the   hernia.     Operation   is   required   when   the   hernia   becomes 

395 


396  DEFORMITIES 

strangulated,  and  it  is  always  to  be  advised  in  older  children  if  a 
cure  is  not  effected  after  two  years'  treatment  by  truss.  Many  of  my 
cases  have  entirely  recovered  in  less  than  six  months. 

UMBILICAL  HERNIA 

Umbilical  hernia  may  be  either  congenital  or  acquired.  However, 
nearly  all  cases  may  be  said  to  be  congenital,  since  the  hernia  is 
due,  either  to  a  failure  in  the  closure  of  the  ventral  laminae,  or  to  a 
defective  development  of  the  parts  at  the  umbilical  opening,  which 
give  way  under  pressure,  such  as  straining  in  whooping-cough  or 
in  colic. 

The  hernia  may  vary  in  diameter  from  one-fourth  inch  to  one 
inch  and  may  protrude  as  much  as  an  inch  and  one-half.  Occa- 
sionally cases  are  seen  in  which  there  is  an  associated  ventral 
hernia  immediately  above  the  umbilical.  Ten  percent  of  dispen- 
sary cases  under  six  months  of  age  have  umbilical  hernia?,  and  it 


Fig.  42.— Umbilical  Hernia  Reduced  and  Adhesive  Plaster  Applied. 

is  by  no  means  rare  among  the  better  classes.  It  usually  makes 
its  appearance  during  the  early  months  of  Ufe. 

Treatment. — The  treatment  is  entirely  mechanical  and  consists 
in  reducing  the  hernia  and  applying  sufficient  pressure  to  prevent 
its  recurrence.  By  far  the  most  effective  means  is  bringing  together 
over  the  umbilicus  (Fig.  42)  the  two  lateral  folds  of  the  skin,  so 
that  they  meet  in  the  median  line.  The  two  folds  of  skin  thus 
placed  form  a  spHnt.  Over  this  is  placed  a  strip  of  Z.  O.  adhesive 
plaster  one  or  tw^o  inches  wide,  the  length  depending  upon  the  size 
of  the  child.  Usually  a  strip  from  four  to  six  inches  long  is  re- 
quired. I  have  found  this  method  much  more  satisfactorv  than  any 
other,  as  it  is  followed  by  a  more  rapid  cure. 

The  objection  to  the  use  of  the  covered  button  or  any  other 
form  of  pad  is  that  unless  it  is  very  large,  it  is  apt  to  make  strong 


sriivjA   itii'iDA  397 

pressure  upon  IIk-  abdominal  optiiinj;,  and  wliik-  it  rcdnci'S  tlir  luTuia, 
tin- pressure  fxcrtcd  upon  the  abdominal  rinj^pri-vfuts  its  rapid  closuri'. 
Not  only  may  it  thus  act  nuchanically  in  pri-vcnlinj;  tlu-  closinj;  in 
of  the  abdominal  wall,  l)ut,  tlirouj^h  intcrfcivncf  with  the  circulation, 
the  nutrition  of  the  musclts  is  intcrfcrc-d  with  and  tlic  weakness 
persists.  Umbilical  trusses  and  bandajjes  have  been  used  n-peatedly 
and  all  have  been  hopi-less  failures,  and  foi  oiu-  reason  chielly  the 
dilTiculty  of  keeping  tluin  in  position.  ,\ii\  inlilli^Hiit  mother 
or  nurse  can  be  tau};hl  in  a  few  miiuites  how  to  apph  the  i)laster 
as  above  suSJi^'Sted.  The  child  may  be  ballud  with  the  plaster 
in  position.  Ordinarily,  it  is  best  (o  a])ply  a  fresh  piece  every  lifth 
day.  Irritation  of  the  skin  under  the  plaster  sometimes  occurs. 
If  there  is  a  tc-ndency  to  excoriation  or  ifdness  of  the  skin,  the 
folds  can  be  made  at  right  anp;les  to  those  previously  luadc  and  tln' 
plaster  aj^ain  apj)lied  at  right  angles  to  tlu'  folds.  Hy  so  doing,  the 
excoriated  skin  reiuains  uncovered.  If  the  hernia  is  not  particularly 
large  and  if  the  case  is  seen  during  the  lirst,  second,  oi  tliird  montli 
of  life,  a  cure  can  be  expected  in  from  three  to  six  nionllis.  The 
yoiuiger  the  child,  the  more  rapid  will  be  the  cure.  Repeatedly, 
when  treatment  was  begun  within  the  lirst  six  weeks,  1  have  seen 
a  large  hernia  completely  cured  in  a  few  months.  In  not  one  of 
my  cases  has  operation  been  necessary. 

VENTRAL  HERNIA 

This  form  of  hernia  is  of  congenital  origin  and  is  only  occasionally 
seen  in  infants.  It  may  be  associated  with  lunbilical  hernia  or  it 
may  occur  independently.  It  may  be  due  to  a  failure  of  the  recti 
to  unite  in  the  median  line  or  it  may  be  due  to  a  weakness  or  an 
imperfect  development  of  the  fibers  of  i  itlui   iiuiselc. 

There  is  rarely  any  great  i)rotrusion  of  the  iilxlomin.d  contents, 
as  in  the  other  forms  of  hernia.  Usually  a  ventral  hernia  manifests 
itself  in  a  fullness  or  a  distinctly  localized  elevation  of  the  skin  over 
the  site  of  the  absent  or  weakened  nuiscle  tissue  in  (he  abdominal 
walls. 

The  application  of  a  four  inch  strip  of  Z.  O.  adhesive  plaster 
one  and  one-  half  to  two  inches  wide-,  placed  Hat  on  the  skin  over 
tlu-  hernia,  is  all  that  will  be  recpiired.  The  support  thus  furnished 
will  have  to  be  continued  for  several  montlis.  Operation  may 
sometimes  be  necessary,  but  it  has  not  l)een  reepiired  in  mv  cases. 

SPINA  BIFIDA 
The  results  of  treatment  of  spina  bifida,  regardless  of  its  type 
or  the  method  employed,  will  scarcely  warrant  us  in  promising 
parents  much  in  the  way  of  improvement.  In  my  hands  the  injec- 
tion of  iodin  has  not  been  of  any  value.  The  pressure  treatment  is 
unsatisfactory.     Surgery    promises    better    results    than    does   any 


398  DEFORMITIES 

other  treatment.  Operative  measures  are  fully  described  in  works 
of  surgery  and  the  results  are  sometimes  brilliant.  Operations, 
however,  are  not  without  immediate  danger,  for  in  a  great  ma- 
jority of  the  cases  portions  of  the  cord  are  within  the  sac,  the 
excision  of  which  may  result  in  permanent  paralysis  and  deformity. 
It  is  the  duty  of  the  family  physician  to  see  that  the  tumor  is  care- 
fully protected  and  kept  clean  and  the  child  properly  nourished 
until  such  time  as  operation  by  excision  or  otherwise  is  thought 
advisable,  which  ordinarily  is  not  until  the  child  is  one  year  of  age. 

HARELIP 
The  time  for  the  operation  for  harelip  depends,  within  certain 
limits,  upon  the  condition  of  the  child.  Some  surgeons  prefer  to 
operate  very  early  and  others  when  the  child  is  several  months 
old.  Ordinarily  the  operation  should  not  be  performed  before  the 
patient  is  one  month  old  or  delayed  after  the  fourth  month,  if  the 
child's  condition  and  the  season  of  the  year  permit.  Operations 
on  young  children  should  not  take  place  during  the  hot  months 
because  of  the  lack  of  resistance  on  the  part  of  a  young  infant  to 
the  shock  of  an  operation,  and  because  of  the  dangers  of  gastro- 
enteric complications,  the  latter  being  considerable.  The  matter 
of  feeding  need  not  hasten  the  operation  if  other  factors  in  the  case 
are  unfavorable  for  it.  The  child  with  harelip  may  be  successfully 
fed  by  gavage  (page  134)  for  an  indefinite  period. 

HEMATOMA  OF  THE  STERNOCLEIDOMASTOID 

The  tumor  which  is  formed  in  a  portion  of  this  muscle  is 
caused  bv  an  injury  during  birth,  and  consists  of  a  rupture  of  the 
muscle-fibers  and  of  the  blood-vessels.  The  tumor  may  be  small, 
not  larger  than  a  filbert,  or  it  may  involve  a  considerable  part  of 
the  muscle  structure.  When  much  of  the  muscle  is  included  in  the 
tumor,  the  head  of  the  patient  is  held  in  a  constrained  position  with 
the  face  directed  toward  the  affected  side.  The  tendency  of  these 
cases  is  to  recover  without  treatment,  but  it  has  seemed  to  me,  from 
an  observation  of  saveral  cases  where  it  was  employed,  that  the 
absorption  of  the  tumor  was  hastened  by  massage,  which  should  be 
practised  for  fifteen  minutes  three  times  a  day.  A  moderate  stretch- 
ing of  the  muscle  by  forcible  rotation  of  the  head  toward  the 
unaffected  side  and  upward  appeared  to  be  of  benefit  in  a  few  cases, 
the  movements  being  practised  at  the  same  time  as  the  massage. 

CLEFT  PALATE 

Cleft  palate  may  involve  either  the  hard  or  soft  palate,  or  both. 

The  time  for  operation,  and  the  nutrition  until  such  time  arrives, 

are  all  that  concern  us.     Operation  should  not  take  place  during  the 

first  year,  and  is  better  performed  between  the  first  and  the  second 


CLEFT  PALATE 


399 


years,  but  not  later  than  the  second,  as  the  result  is  much  more  satis- 
factory than  if  left  to  a  later  age.  The  feeding  of  the  patient  is 
usually  considerably  interfered  with.  The  child  is  rarely  able  to 
take  the  bottle,  and  the  various  devices  for  the  formation  of  an 
artificial  hard  palate  are  usually  failures.  Sucking  on  the  bottle  or 
nipple  is,  of  course,  out  of  the  question.  A  spoon  or  a  large  medi- 
cine-dropper may  be  employed  in  feeding,  but  their  use  is  tiresome 
both  for  the  attendant  and  the  child.  By  far  the  best  method  of 
feeding  in  these  cases  is  by  gavage  (page  134).  The  nutrition  of  the 
child  may  thus  be  maintained  for  months,  and  with  results  quite  as 
good  as  by  natural  methods.  I  have  a  child  ten  months  of  age 
under  my  care  at  the  present  time  who  has  always  been  fed  by 
gavage  at  intervals  suitable  for  his  age,  and  his  development  has 
been  perfect. 


DISEASES  OF  THE  SKIN 

ECZEMA 

When  one  considers  the  sensitive  nature  of  the  skin  and  its 
constant  exposure  to  all  sorts  of  irritating  influences  it  cannot  be 
surprising  that  skin  affections  are  more  frequently  seen  in  infants 
than  are  any  other  ailments;  and  when  one  recognizes  in  the  skin 
an  organ  of  absorption,  secretion,  and  excretion,  the  importance 
of  a  careful  study  of  its  lesions  will  be  self-evident.  Inasmuch, 
therefore,  as  what  is  known  as  eczema  is  characterized  both  by 
acute  and  chronic  inflammations  of  the  skin,  the  fact  that  in  its 
different  forms  it  comprises  a  large  percentage  of  the  skin  diseases 
of  young  children  is  readily  understood.  From  an  etiologic  stand- 
point, eczema  in  children  may  be  divided  primarily  into  two  classes: 
those  forms  due  to  causes  operating  from  within — systemic  condi- 
tions; and  those  due  to  causes  operating  from  without — local  irri- 
tations of  whatever  nature. 

Manifestations.  The  manifestations  of  eczema  are  subject  to 
most  sudden  changes,  an  apparently  normal  skin  today  developing  a 
weeping  eczema  tomorrow,  while  a  few  days  later  the  skin  may  again 
be  clear.  It  is  difiicult  and  unnecessary  in  children  to  attempt 
any  such  differentiation  of  the  various  types  of  eczema  as  is  laid 
down  in  works  on  dermatology ;  and  indeed  such  a  differentiation 
is  difficult,  for  the  reason  that  in  children  eczema  is  not  confined 
to  the  special  adult  types,  but  rather  to  various  combinations  of 
lesions, — every  variety  of  papule,  vesicle,  pustule,  and  fissure  being 
often  seen  in  one  patient  on  a  surface  area  of  only  a  few  square 
inches.  Infections  of  the  involved  areas  resulting  in  pustules  and 
furuncles  are  more  common  in  children  than  in  adults,  because 
of  the  ready  inoculation  and  transmission  of  bacteria  through 
manipulation  and  scratching,  and  because  of  the  diminished  re- 
sistance offered  by  the  child  to  pyogenic  organisms. 

Cases  Originating  from  Within. — Such  cases  are  by  far  the  more 
frequent  and  the  more  troublesome.  The  most  susceptible  age  is 
from  one  to  twelve  months.  While  cases  which  have  developed 
during  the  earlier  months  may  be  carried  over  into  the  second  or 
into  the  third  year,  it  is  comparatively  rare  for  this  to  happen, 
as  it  is  also  rare  for  cases  to  develop  after  the  nursing  age.  At 
this  early  period  the  inflammatory  process  may  be  limited  to  a 
round  weeping  spot  on  each  cheek,  or  it  may  involve  all  the  flexor 
surfaces,  or  it  may  cover  larger  portions  of  the  skin  surface  and 
show  all  the  clinical  phases  of  the  disease.     The  physical  condition 

400 


ECZEMA 


401 


of  the  child  exerts  no  influence  upon  the  development  or  persistence 
of  the  eczema. 

Some  of  my  healthiest  nursing  babies— those  who  made  most 
satisfactory  progress  and  were  well  in  every  other  respect — were 
sufferers  from  eczema  until  the  nursing  period  was  over  or  until 
nursing  was  discontinued  and  other  food  given.  In  fact,  the  ma- 
jority of  my  cases,  both  breast-fed  and  bottle-fed,  have  been  in 
children  whose  condition  was  otherwise  satisfactory.  There  were 
others,  to  be  sure,  who  suffered  from  malnutrition  or  who  were 
difficult  feeding  cases.  In  some  of  these  the  eczema  was,  doubtless, 
a  factor  in  causing  the  malnutrition ;  for  on  account  of  the  excessive 
itching,  restlessness,  and  sleeplessness,  the  child's  strength  had 
become  so  markedly  reduced  that  malnutrition  was  just  as  Uable 
to  be  a  result  as  a  cause  of  the  eczema.  Athreptic  and  malnutrition 
children  are  very  apt  to  be  free  from  eczema  of  an  acute  inflamma- 
tory type ;  the  cases  we  are  considering,  however,  are  due  to  intes- 
tinal indigestion  and  faulty  metabolism  of  such  a  nature  as  not  to 
interfere  with  nutrition.  We  know  from  cUnical  experience  that 
no  one  cause  is  operative  in  all  cases,  and  we  know  also  that  our 
management,  to  be  effective,  must  be  directed  toward  the  in- 
testinal tract  and  the  liver. 

Several  of  my  patients  who  have  been  sufferers  from  eczema 
in  babyhood  have  in  later  life  developed  some  recurrent  illness, 
such  as  bronchitis,  asthma,  or  recurrent  vomiting.  Not  a  few  of 
these  persistent  eczemas  in  infants  are  associated  with  gout  and 
rheumatism.  In  out-patient  work  a  great  many  cases  of  acute 
eczema  are  seen,  and  they  are  not  infrequent  in  office  pediatric  work. 
Not  all  cases  are  relieved  by  treatment,  but  usually  some  way  may 
be  found  to  relieve  most  of  them.  In  a  few,  regardless  of  treatment, 
the  eczema  persists  in  a  less  aggravated  form,  until  the  child  is 
weaned  or  until  milk-feeding  can  in  a  measure  be  discontinued. 

Treatment. ^In  the  breast-fed,  a  proper  regulation  of  the  nurs- 
ing as  regards  time  and  quantity  may  be  sufficient.  The  relief  of 
the  constipation  of  the  mother  is  all  that  is  required  in  some  eczem- 
atous,  breast-fed  infants.  The  eczema  which  is  due  to  high  fat  or 
high  proteid,  or  both,  in  the  breast-fed  may  be  relieved  by  regulating 
the  diet  of  the  mother  (page  69)  and  by  insisting  upon  reasonable 
exercise.  If  the  child  is  thriving,  making  a  satisfactory  gain  in 
weight,  the  nursing  should  never  be  discontinued  because  of  the  ec- 
zema. If  the  mother  or  wet-nurse  has  been  indulging  in  too  rich 
food,  drinking  beer,  tea,  or  coffee  in  excess,  they  should  be  discon- 
tinued and  a  very  plain  diet  substituted.  Two  grains  of  bicarbonate 
of  soda  given  in  two  drams  of  water  before  each  nursing  is  often  of 
service.  Of  late,  in  those  cases  of  eczema  in  which  the  urine  has 
shown  marked  acidity  I  have  given  with  apparent  b2nefit  two  grains 
of  citrate  of  potash,  three  times  daily. 
26 


402  DISEASES    OF    THE    SKIN 

In  the  bottle-fed,  the  correction  of  errors  in  feeding  is  easier, 
and,  as  a  whole,  such  cases  are  more  satisfactory  to  treat  than  are 
the  breast-fed  cases.  The  eczema  may  respond  to  the  treatment 
of  constipation  if  it  exists.  It  is  impossible  in  a  given  case  to  tell 
whether  the  feeding  as  a  whole  is  a  cause  of  the  trouble,  or  some 
one  of  the  nutritional  elements  is  at  fault.  My  usual  way  in  the 
bottle-fed  is  to  give  a  food  upon  which  the  child  may  be  ex- 
pected to  thrive.  If  the  eczema  is  pronounced,  the  sugar,  for  a 
week,  is  reduced  perhaps  to  4  percent.  When  this  produces  no 
effect,  the  6  or  7  percent  of  sugar  is  resumed  and  the  fat  or  pro- 
teid  reduced.  Working  in  this  way,  by  a  process  of  exclusion, 
I  have  discovered  which  element  in  the  food  was  apparently  at 
fault  and  the  eczema  has  responded  to  its  correction.  The  food 
should  never  be  so  manipulated  that  the  infant  will  not  thrive. 

Illustrative  Cases. — One  of  my  patients,  a  baby  otherwise 
normal,  had  the  most  pronounced  general  eczema  that  I  have  ever 
seen,  the  entire  skin  surface  being  involved.  For  seven  months — 
until  he  was  past  one  year  of  age — I  was  unable  to  give  this  pa- 
tient more  than  i  percent  of  fat.  An  increase  to  1.5  percent  of 
fat  would  be  followed  in  one-half  hour  by  an  inflammation  and 
redness  of  the  skin.  In  another  case  almost  as  severe — one  which 
I  saw  at  the  ninth  month — I  was  unable  to  give  cow's  milk  in  any 
form.  The  condition  was  so  aggravated  that  I  discontinued  en- 
tirely the  fresh  cow's  milk  and  put  the  child  on  condensed  milk, 
when  the  skin  cleared  promptly  without  any  other  treatment  what- 
ever. About  six  weeks  later  fresh  cow's  milk  was  again  tried  in 
small  quantities,  with  a  prompt  return  of  the  eczema.  At  different 
intervals  the  cow's  milk  was  given  for  one  or  two  feedings  daily, 
but  we  were  always  obliged  to  discontinue  it  because  of  the  signs 
of  the  old  trouble  which  immediately  appeared  after  two  or  three 
cow's-milk  feedings  had  been  given. 

In  these  obstinate  cases  as  the  urine  is  usually  very  acid,  and 
a  deposit  of  urates  will  be  found  on  the  napkin,  I  invariably  give 
bicarbonate  of  soda,  one  grain  to  one  ounce  of  food,  or  two  grains 
of  citrate  of  potash  three  or  four  times  daily. 

Local  Treatment. — The  local  treatment  in  the  cases  of  internal 
origin  is  very  unsatisfactory,  and  all  that  can  be  accomplished  is  to 
relieve  the  itching  and  make  the  child  more  comfortable.  It  may 
safely  be  said  that  in  the  treatment  of  eczema  in  infants  more  harm 
than  good  usually  results  from  local  measures.  As  a  rule,  too  strong 
lotions  and  ointments  are  used,  which,  while  they  may  not  increase 
the  irritation,  produce  enough  to  retard  recovery. 

When  the  face  is  involved,  showing  a  bright  red  or  weeping 
surface,  the  application  of  bassorin  paste  usually  gives  relief.  The 
paste  dries  on  the  parts  and  forms  a  firm  protective  dressing.  The 
oil  of  cade — one-half  dram  to  one  dram,  to  one  ounce  of  collodion — 


ECZIvMA  403 

may  be  used.  If  there  is  a  very  acute  infection,  fifteen  minims 
of  the  oil  of  cade  to  an  ounce  of  either  bassorin  paste  or  collodion  is 
the  proper  proportion.  The  face  should  not  be  washed  nor  the  appli- 
cations removed.  As  it  peels  off  it  should  be  freshly  applied.  The 
bassorin  paste '  will  not  bear  the  addition  of  liquids  in  any  consider- 
able amount,  but  the  oxid  of  zinc  may  be  combined  with  it,  as  may 
also  ichthyol  and  tar  in  small  amounts.  Ointments  applied  to 
the  face,  unprotected,  are  soon  rubbed  off  and  soil  the  clothing. 
The  use  of  a  mask  is  recommended  in  some  out-patient  and  hospital 
cases,  but  strongly  objected  to  in  private  practice.  When  an  oint- 
ment can  be  applied  under  a  mask,  or  when  it  is  to  be  used  on  other 
parts  of  the  body  where  it  may  be  bound  upon  the  parts,  the  pre- 
parations of  tar  afford  greater  relief  than  does  any  other  application. 
An  ointment  composed  of  the  unguentem  picis,  U.  S.  P.,  one  part, 
with  imguentem  aquae  rosae,  from  four  to  six  parts, — the  strength 
used  depending  upon  the  irritability  of  the  skin, — may  be  applied 
at  least  morning  and  evening.  It  should  be  thickly  spread  upon  old 
linen  and  bound  firmly  but  gently  to  the  parts.  If  the  existing  irrita- 
tion is  at  all  increased  by  the  appHcation,  it  should  be  weakened 
by  a  reduction  in  the  amount  of  tar  used.  In  spite  of  the  eczema 
these  infants  must  be  bathed.  The  bran  or  soda  bath  (page  31) 
may  be  used,  care  being  taken  to  avoid  too  much  friction  of  the 
skin. 

Eczema  Due  to  Irritation  from  Without. — Eczema  due  to  irri- 
tation from  without  is  not  unusual  with  sensitive  skins.  It  may  be 
caused  by  strong  soaps,  by  vigorous  rubbing,  by  irritating  clothing, 
such  as  woolens,  etc.,  or  it  may  result  from  counter-irritation  applied 
because  of  some  respiratory  disorder.  Obviously  the  management 
of  these  cases  depends  upon  the  removal  of  the  source  of  irritation. 
In  some  of  my  cases  where  woolens  cannot  be  worn  I  advise  that 
the  linen  mesh  be  substituted;  in  others  that  the  garment  which 
comes  in  contact  with  the  skin  be  lined  with  thin  soft  linen. 

Eczema  Intertrigo. — Eczema  intertrigo  is  a  result  of  maceration 
of  the  skin,  where  two  skin  surfaces  are  in  constant  apposition. 
It  is  most  frequently  seen  in  the  skin-folds  of  the  neck,  the  groin, 
under  the  arms,  and  on  the  flexor  surfaces  at  the  elbow-joint.  At 
first  there  is  usually  a  simple  erythema,  which  if  neglected 
develops  into  a  characteristic  eczema.  The  treatment  consists 
in  separating  the  opposed  surfaces  by  pledgets  of  cotton  freely 
dusted  with  equal  parts  of  powdered  starch  and  oxid  of  zinc.  The 
cotton  should  be  removed  as  soon  as  it  becomes  moist  and  fresh  ap- 
plications made.  Linen  or  gauze  may  be  used  in  the  same  way. 
Usually  this  treatment  promptly  relieves  the  condition. 

A  similar  maceration  of  the  skin  may  occur  when  the  genitals 
and  the  skin  over  the  inner  portion  of  the  thighs,  the  buttocks, 
'  Manufactured  by  Lehn  and  Fink,  New  York. 


404  DISEASES    OF   THE    SKIN 

and  the  lower  abdomen  are  allowed  to  remain  wet  with  decom- 
posing urine.  With  very  few  exceptions  these  cases  are  due  to 
neglect.  Athreptic  and  malnutrition  infants  furnish  many  of  the 
cases.  In  a  few  infants  well  cared  for,  intertrigo  may  develop. 
In  these,  it  may  be  explained  by  a  very  acid  urine  or  it  may  be 
one  of  the  manifestations  of  seborrheic  eczema  (page  405). 

The  treatment,  with  the  exception  of  the  seborrheic  type,  con- 
sists in  neutralizing  the  urine  by  the  use  of  bicarbonate  of  soda, 
—  two  grains  three  times  daily, — by  protecting  the  skin  surfaces, 
and,  by  attention  to  the  napkin,  preventing  irritation  from  the  dis- 
charges. Dusting-powders  are  of  very  little  use  here.  The  method 
which  has  been  most  satisfactory,  and  which  I  have  followed 
with  success  for  years  even  in  the  most  unpromising  subjects,  is 
as  follows:  The  mother  or  nurse  is  instructed  to  keep  close  watch 
of  the  napkin  and  change  it  as  soon  as  it  is  soiled  and  not  to  reapply 
it  until  it  has  been  washed.  She  is  further  instructed  to  prepare 
pieces  of  gauze  or  old  linen  of  such  shape  and  size  as  to  cover  the 
denuded  surfaces.  On  these  slips  of  linen  she  is  directed  to  spread 
zinc  ointment  most  plentifully.  The  dressing  is  then  applied  to  the 
parts  and  is  to  be  changed  several  times  daily.  Over  this  dressing 
the  napkin  is  placed.  The  urine,  which  is  chiefly  at  fault,  is  pre- 
vented by  the  ointment  dressings  from  coming  in  contact  with  the 
skin,  the  treatment  being  solely  protective.  At  the  same  time 
a  quantity  of  absorbent  cotton  is  placed  next  to  the  genitals  so  as 
to  absorb  the  urine  as  it  is  passed  and  thus  prevent  its  general  dis- 
tribution over  the  parts.  If  the  ointment  is  simply  spread  over 
the  skin  and  the  napkin  applied,  it  will  soon  be  absorbed  by  the 
napkin  and  be  of  no  service.  When  the  case  is  well  advanced 
toward  recovery,  scrupulous  cleanliness  and  a  dusting-powder  com- 
posed of  equal  parts  of  powdered  starch  and  oxid  of  zinc  will  usually 
be  all  that  is  required. 

Chronic  Eczema  in  Older  Children. — A  form  of  chronic  eczema 
of  comparatively  frequent  occurrence  in  out-patient  cases  remains 
to  be  described.  Some  writers  refer  to  it  as  a  "neurotic  eczema  " 
and  others  as  a  "reflex  eczema."  The  predominating  lesions  are 
papules.  The  first  local  manifestations  are  papules,  and  they 
remain  papules  unless  other  changes  are  produced  by  scratching. 
Oftentimes  the  papule  is  tipped  with  a  black  speck  which  repre- 
sents dried  blood  and  dirt — a  result  of  scratching.  A  large  portion 
of  the  skin  surface  may  be  covered  by  the  eruption  or  it  may  be 
localized  on  the  arms  or  thighs.  Itching  is  a  troublesome  feature 
of  these  cases;  in  some  it  is  almost  unbearable,  and  the  patient 
is  often  presented  with  the  skin  torn  and  bleeding.  The  disease  is 
without  doubt  due  to  some  low  form  of  intestinal  toxemia.  Often 
the  patient  suffers  from  constipation;  he  may  have  a  large,  dis- 
tended abdomen  and  not  infrequently  quite  offensive  stools. 


ECZEMA  405 

Treatment. — The  treatment  consists  largely  of  internal  measures. 
The  best  initial  internal  medication  for  this  condition  is  calomel  or 
rhubarb  and  soda,  not  sufficient  to  produce  purging,  although  at  the 
outset  a  purge  may  be  of  advantage.  For  a  child  from  four  to  six 
years  of  age,  from  two  to  four  grains  of  rhubarb  with  six  grains  of  bicar- 
bonate of  soda  should  be  given  twice  daily  between  meals,  for  two, 
three,  or  more  weeks;  sufficient  should  be  given  to  produce  one 
or,  better,  two  soft  movements  daily.  The  rhubarb  and  soda  may 
be  given  in  two  drams  of  a  solution  of  equal  parts  of  aromatic  syrup  of 
rhubarb  and  water.  Every  fourth  night  at  bedtime  one-fourth  grain 
of  calomel  is  given.  The  diet  suitable  for  the  child's  age  (pp.  129- 
132)  may  be  given.  It  generally  means  a  radical  change  in  the 
feeding  methods,  as  the  records  usually  show  that  these  children  have 
been  very  badly  fed.  Nothing  is  to  be  given  between  meals.  The 
best  local  treatment  is  an  ointment  of  salicylic  acid  or  tar,  either 
separately  or  combined.  If  there  is  an  acute  dermatitis  as  a  result 
of  scratching,  only  a  weak  solution  of  salicylic  acid  should  be  used, 
or  it  may  be  wise  to  omit  it  entirely  until  the  dermatitis  has  subsided, 
using  instead  the  plain  zinc  ointment,  U.  S.  P.,  with  the  addition  of 
menthol,  as  follows: 

I^.     Mentholi gr.  x 

Unguenti  zinci  oxidi 5j 

After  the  acute  dermatitis  has  subsided  the  following  prescription 
answers  well: 

I^.     Acidi  salicylatis gr.  x 

Unguenti  picis  U.  S.  P 5ss 

Unguenti  aquae  rosae q.  s.  ad   5ij 

The  ointment  should  be  used  twice  daily,  bound  to  the  parts 
so  as  completely  to  cover  the  surfaces,  thereby  getting  the  full 
benefit  of  the  treatment  and  at  the  same  time  protecting  the  skin 
from  further  irritation  by  scratching.  The  cases  are  usually  obsti- 
nate and  treatment  will  have  to  be  continued  from  three  to  six  weeks. 
In  those  children  who  have  been  suffering  from  this  form  of  eczema 
for  a  long  time  and  who  show  extensive  lesions,  two  or  three  months 
may  be  required  to  complete  a  cure. 

Seborrheic  Eczema. — This  form  of  eczema  is  due  to  an  excessive 
secretion  of  the  sebaceous  glands  which  is  dependent  upon  a  func- 
tional derangement,  probably  inflammatory  in  character.  It  is 
believed  by  some  dermatologists  that  the  disease  is  dependent  upon 
a  specific  infection. 

Seborrhea  Capitis  {Milk  Crust). — The  form  in  which  it  is  most 
frequently  seen  in  children  develops  on  the  head  in  the  form  of 
thick,  dirty,  yellow  crusts,  commonly  known  as  "milk  crust."  In 
mild  cases  the  crusts  may  be  isolated  or  there  may  be  one  large 


4o6  DISEASES    OF    THE    SKIN 

patch  with  several  surrounding  smaller  areas.  In  some  cases  the 
exudation  is  thick  and  uniform  and  covers  the  vertex  of  the  head 
like  a  mask.  The  exudation  consists  of  sebum,  dirt,  and  desqua- 
mated epithelium. 

Treatment. — The  first  step  in  the  treatment  is  to  remove 
the  crusts.  The  hair  should  be  cut  very  short.  If  only  a  few  areas 
are  involved,  anointing  the  parts  wuth  vaselin  several  times  daily 
will  soften  them  so  that  they  may  be  removed.  If  the  crust  is  thick 
and  extensive  it  is  best  to  soften  it  with  sterilized  olive  oil,  which 
is  appHed  on  gauze  or  old  linen.  The  material  used,  saturated  with 
the  oil,  is  held  in  place  by  a  cap  made  of  cheese-cloth.  If  the  dressing 
is  applied  at  bedtime  the  crusts  may  often  be  removed  the  following 
morning.  In  cases  in  which  the  exudation  has  existed  for  a  long 
time  and  is  very  hard,  it  may  require  two  or  three  days,  with  frequent 
fresh  applications  of  the  oil,  to  soften  it  sufficiently  for  removal 
without  injury  to  the  skin.  When  thoroughly  softened  it  should 
be  washed  off  with  castile  soap  and  warm  water.  After  the  crusts 
are  removed,  a  reddish,  slightly  inflamed  skin  will  usually  be  found 
underneath.  To  this  is  applied  an  ointment  of  resorcin  and  vaselin, 
twenty  grains  to  the  ounce.  The  ointment  is  spread  on  linen  or  lint 
and  applied  to  the  parts,  the  gauze  cap  being  worn  to  hold  it  in 
position.  In  many  cases  this  treatment,  used  only  at  night,  will  be 
sufficient ;  only  the  most  aggravated  cases  need  wear  the  cap  during 
the  day.  A  few  applications  of  the  ointment  to  the  parts  during  the 
day  will  usually  be  all  that  is  needed.  A  few  days'  treatment  will 
often  relieve  the  worst  cases  of  seborrhea  capitis,  after  the  scalp 
has  been  freed  from  crusts.  I  have  yet  to  see  a  case  which  did 
not  respond  when  this  treatment  was  properly  carried  out.  It  is 
to  be  remembered,  however,  that  in  these  cases  there  is  a  tendency 
for  the  exudation  to  return.  Mothers  and  nurses  are  instructed 
to  keep  the  ointment  in  the  nursery  for  use  upon  the  first  appear- 
ance of  the  exudation.  In  children,  seborrheic  eczema,  according  to 
my  observation,  is  comparatively  unusual  in  other  portions  of  the 
body.  Associated  with  the  seborrhea  of  the  scalp,  the  forehead 
and  face  may  be  involved.  In  these  situations  also  resorcin  is 
useful,  but  must  be  used  in  much  weaker  strength — from  0.5  to  i 
percent. 

Sebonhca  lutcrtn'go. — At  rare  intervals  cases  of  intertrigo  are 
encountered  upon  which  no  impression  whatever  is  made  by  the 
methods  of  treatment  suggested  on  page  404.  Several  years  ago 
Dr.  George  T.  Elliot,  of  New  York,  called  my  attention  to  the  fact 
that  these  cases  were  of  seborrheic  origin,  and  that  a  change  from 
the  ordinary  treatment  to  that  ordinarily  used  for  seborrheic  ec- 
zema would  prove  his  contention.  In  the  cases  in  question,  and 
in  those  that  I  have  seen  since,  the  point  made  by  him  has  been 
confirmed  by    the    treatment.       Cases   of    seborrhea  intertrigo  are 


urticaria;  hives;  nettle-rash  407 

generally  associated  with  seborrhea  elsewhere,  usually  of  the  head, 
and  show  erythema,  a  tendency  to  dryness  of  the  skin,  and  des- 
quamation. 

The  treatment  in  this  form  of  intertrigo  consists  in  cleanhncss 
and  diet,  as  mentioned  under  Intertrigo,  page  404.  In  addition  to  the 
usual  means,  from  0.5  to  i  percent  of  resorcin  should  be  added  to 
the  ungt.  zinci  oxidi  which  is  used  as  a  dressing.  Seborrheic  eczema 
is  not  as  difficult  of  management  as  the  other  forms  of  eczema  in 
children,  but  there  is  a  great  tendency  for  it  to  return,  particularly 
in  cases  of  low  vitality. 

URTICARIA;  HIVES;  NETTLE-RASH 
Urticaria  is  characterized  by  the  sudden  appearance  and  dis- 
appearance on  the  skin  surface  of  wheals  of  vasomotor  origin.  The 
wheals,  which  are  associated  with  intense  itching  and  burning,  are 
of  different  varieties  and  subside  without  desquamation.  They 
vary  considerably  in  size  and  shape,  which  fact  has  given  rise  to 
a  differentiation  into  types  for  purposes  of  diagnosis.  For  our 
purpose  a  division  has  to  be  made  from  the  etiologic  standpoint 
only. 

Urticaria  may  be  due  to  agencies  operating  either  from  without  or 
from  within.  An  agency  operating  from  without  may  be  an  irritant 
of  almost  any  nature — the  bites  of  insects,  clothing  which  may 
irritate  the  skin,  or  clothing  which  is  too  tight.  Contact  with 
different  plants  may  also  produce  the  wheals.  Such  causes  as  these, 
however,  are  factors  in  but  comparatively  few  cases.  The  manage- 
ment, obviously,  is  the  removal  of  the  source  of  irritation  and  the 
apphcation  of  a  simple  ointment,  such  as  one  composed  of  ten 
grains  of  menthol  to  one  ounce  of  cold-cream,  or  the  parts  may 
be  bathed  with  a  i  percent  carbolic  solution. 

Irritation  arising  from  internal  sources  is  the  cause  of  the  condition 
in  at  least  95  percent  of  the  cases.  The  use  of  certain  drugs  may 
furnish  sufficient  irritation  to  cause  the  outbreak.  I  have  in  not  a 
few  instances  seen  hives  due  to  quinin,  arsenic,  or  antipyrin.  The 
administration  of  diphtheritic  antitoxin  produces  urticaria  in  from 
15  to  20  percent  of  the  cases.  Certain  articles  of  food,  such  as 
strawberries,  tomatoes,  oatmeal,  and  buckwheat,  invariably  cause 
urticaria  in  some  children.  Digestive  disturbances  of  any'nature, 
whether  acute  or  chronic  in  character,  may  cause  urticaria.  In 
an  attack,  therefore,  where  no  external  cause  can  be  discovered, 
and  where  drug  idiosyncrasies  can  be  ehminated,  it  is  fair  to  assume 
that  the  source  is  the  intestinal  canal.  A  safe  procedure  is  to  give 
a  full  dose  of  castor  oil — two  to  four  teaspoonfuls — or  one  grain 
of  calomel  in  divided  doses,  followed  the  next  morning  by  the 
citrate  or  the  milk  of  magnesia.  At  the  same  time,  the  diet,  re- 
gardless of  the  age,  should   be    reduced   to    broths  and  gruels,  to 


408  DISEASES    OF   THE    SKIN 

which  toast  or  dried  bread  may  be  added  if  the  patient  has  been 
accustomed  to  it.  Milk  should  not  be  given.  A  laxative,  a  reduced 
diet,  and  the  application  of  the  menthol  ointment  already  re- 
ferred to  will  usually  be  all  that  is  required.  In  those  that  persist 
in  spite  of  these  measures,  which  include  the  antitoxin  cases,  sali- 
cylate of  soda  (wintergreen)  will  bring  them  to  a  termination 
sooner  than  will  any  other  measure.  For  a  child  three  years  of 
age  two  grains  of  the  salicylate  of  soda  may  be  given  every  two 
hours,  with  four  grains  of  the  bicarbonate  of  soda — five  doses  being 
given  in  twenty-four  hours.  After  this  age  from  three  to  four 
grains  of  the  salicylate  may  be  given  at  a  dose — from  twelve  to 
twenty-four  grains  in  twenty-four  hours.  Certain  children  appear 
to  be  predisposed  to  urticaria  and  give  a  history  of  having  had 
several  attacks.  Children  who  suffer  from  persistent  intestinal  in- 
digestion are  very  liable  to  recurrent  attacks,  which  are  sometimes 
very  obstinate  in  character, 

IMPETIGO  CONTAGIOSA 

This  disease  is  dependent  upon  a  localized  skin  infection.  It 
is  contagious,  several  children  in  the  same  family  or  school  often 
having  the  disease  at  the  same  time.  I  have  known  one  school- 
child  to  infect  an  entire  class  of  twenty.  Cases  of  impetigo  are 
seen  almost  daily  in  out-patient  work.  There  are  no  constitutional 
symptoms,  there  is  rarely  any  itching,  the  only  evidence  of  the 
disease  being  disfigurement  of  the  skin  occasioned  by  the  dry, 
adherent  crusts.  The  encrusted  areas  may  be  isolated  or  they  may 
coalesce,  forming  large  masses. 

Treatment. — The  most  satisfactory  treatment  with  me  has  been 
to  soften  the  crusts  with  sterilized  oHve  oil  applied  on  gauze, 
the  gauze  having  first  been  saturated  with  the  oil.  The  oil-soaked 
gauze  is  then  bound  to  the  parts.  Usually  in  twenty-four  hours 
the  crusts  mav  readilv  be  removed.  Afterward  an  ointment  com- 
posed of  ID  percent  boric  acid  in  ungt.  aquae  rosae,  or  one  composed 
of  lo  percent  ichthyol  in  vaselin,  should  be  appHed  on  sterile  gauze 
and  bound  to  the  suppurating  surface.  The  dressing  should  be 
changed  at  least  night  and  morning.  Recovery  is  usually  complete 
in  from  two  to  three  days,  ^\^hen  the  crusts  are  on  the  lips  or 
other  portions  of  the  face  where  the  dressing  described  cannot  readily 
be  applied,  they  should  be  kept  moist  with  either  the  boric  acid  or 
ichthyol  ointment.  Fresh  ointment  should  be  applied  at  least  every 
three  hours,  both  before  and  after  the  crusts  are  removed,  if  treated 
without  the  use  of  the  gauze. 

PEMPHIGUS 
Pemphigus  in  the  newly  born  is  an  infection  of  the  skin  mani- 
festing itself  in  a  bullous  eruption  which  may  appear  on  any  portion 


ERYTHEMA    NODOSUM  409 

of  the  skin  surface.  An  epidemic  of  pemphigus  occurred  a  few  years 
ago  in  the  New  York  Infant  Asylum.  The  patients  were  mostly 
well-nourished  infants,  and  nearly  all  that  were  born  during  a 
period  of  four  weeks,  twenty-six  in  number,  developed  the  disease. 
The  blebs  varied  in  size  from  one-eighth  to  one-half  inch  in  diameter 
and  were  filled  with  light  yellow  serum.  The  examination  of  the 
serum  showed  uniformly  a  pure  culture  of  the  staphylococcus  albus. 

Treatment. — The  management  consisted  in  opening  the  blebs  and 
in  the  application  of  various  antiseptic  solutions  and  ointments. 
Not  much  improvement  followed  the  treatment,  nothing  worthy  of 
note  being  discovered  until  creolin  baths  were  used.  This  treatment 
not  only  relieved  those  cases  which  had  developed,  but  the  systematic 
bathing  in  a  i  percent  creolin  solution  of  all  the  newly  born  in  the 
institution  prevented  the  spread  of  the  infection. 

In  two  cases  seen  by  me  in  consultation,  pemphigus  was  associ- 
ated with  a  marked  syphilitic  infection.  The  patients  lived  in  the 
country  at  a  considerable  distance  from  New  York  city  and  facilities 
for  taking  the  serum  for  examination  were  not  at  hand.  In  a  general 
way  the  infants  presented  the  same  clinical  appearance,  with  the  ex- 
ception that  the  syphilitic  cases  were  much  more  severe.  There 
was  fever  with  considerable  dermatitis.  The  blebs  also  were  pres- 
ent on  the  palms  of  the  hands  and  soles  of  the  feet,  which  was  not 
the  case  in  the  simple  staphylococcus  cases.  Both  the  syphilitic 
cases  terminated  fatally  within  twenty-four  hours  after  my  visit. 

ERYTHEMA  NODOSUM 

Erythema  nodosum  is  characterized  by  the  formation  in  the 
skin  and  subcutaneous  connective  tissue  of  multiple  brownish 
nodules  of  varying  size.  They  are  most  frequently  seen  over  the 
anterior  surface  of  the  leg,  less  frequently  posteriorly.  They  are 
exceedingly  painful  to  the  touch.  In  two  of  my  cases  they  were 
associated  with  peliosis  rheumatica,  and  all  were  in  rheumatic 
subjects.  Pigmentation  follows  the  disappearance  of  the  nodules. 
There  is  usually  moderate  fever  and  the  child  complains  of  general 
soreness  and  pain  throughout  the  body,  in  addition  to  the  pain 
caused  by  the  nodules. 

Treatment. — The  patient  should  be  kept  in  bed  until  the  acute 
febrile  period  is  passed  and  the  nodules  begin  to  disappear.  The 
treatment  is  begun  with  the  administration  of  one  or  two  grains 
of  calomel  followed  bv  a  saline  laxative.  As  the  disease  is  probably 
one  of  the  many  protean  manifestations  of  rheumatism,  it  should  be 
treated  as  to  diet  and  medication  according  to  the  suggestions  laid 
down  in  the  section  on  Rheumatism.  The  most  satisfactory  local 
measure  for  the  relief  of  pain  is  the  lead  and  opium  solution,  U.  S.  P. 
Soft  old  linen  or  gauze  is  moistened  with  the  warm  solution  and 
applied  to  the  parts,  over  which  oiled  silk  or  rubber  tissue  is  placed 


4IO  DISEASES   OF   THE   SKIN 

to    prevent   too    rapid   evaporation  and  held  in  position  by  ban- 


Illustrative  Case. — A  patient,  at  present  under  treatment,  is 
having  her  third  crop  of  nodules,  the  different  crops  having  appeared 
at  intervals  of  about  three  months.  The  first  attack  was  associated 
with  peUosis  and  urticaria.  The  treatment  which  I  had  emploved 
successfully  previous  to  this  case  was  that  of  the  salicylate  and 
bicarbonate  of  soda,  and  antirheumatic  diet.  This  patient,  who  is 
markedly  rheumatic,  had  taken  large  quantities  of  the  salicylate, 
and  its  readministration  had  no  effect;  but  the  nodules  began 
to  diminish  and  disappeared  completely  in  the  two  previous  attacks 
under  the  administration  of  thirty  grains  daily  of  the  iodid  of  pot- 
ash.    The  present  attack  is  also  subsiding  under  its  influence. 

The  duration  of  my  cases  has  been  from  ten  days  to  three  weeks, 
with  the  exception  of  the  one  referred  to,  which  persisted  for  six 
weeks,  or  until  the  iodid  w^as  brought  into  use,  when  the  improve- 
ment was  prompt. 

ERYTHEMA  MULTIFORME 

As  its  name  indicates,  this  disease  manifests  itself  in  many  differ- 
ent forms.  There  may  be  reddened  papules,  macules,  and  erythema- 
tous areas,  all  of  which  are  most  frequently  found  over  the  dorsal 
surfaces.  In  children  there  are  usually  associated  disturbing  dis- 
orders of  indigestion.  Children  of  rheumatic  inheritance  are  the  most 
frequent  sufferers.  The  condition  is  often  confused  with  urticaria.  As 
a  result  of  the  infiltration  into  the  skin,  the  lesion  of  erythema  mul- 
tiforme requires  several  days  for  resolution  to  take  place,  while  the 
lesions  in  urticaria  are  very  transient  in  character,  rapidly  appearing 
and  disappearing.     In  erythema  there  is  usually  very  little  itching. 

The  treatment  consists  in  relieving  the  constipation,  or  whatever 
digestive  disorder  may  exist,  and  the  use  of  salicylate  of  soda ;  for  a 
child  five  years  of  age,  from  eight  to  twelve  grains  daily  should  be 
given,  in  divided  doses  after  meals.  In  case  there  is  itching  or  irri- 
tation of  the  parts,  an  ointment  composed  of  menthol,  ten  grains  to 
one  ounce  of  ungt.  aquae  rosae,  will  usually  furnish  relief.  The  erup- 
tion seldom  lasts  longer  than  a  week.  A  pigmented  area  may  re- 
main at  the  site  of  the  lesion. 

RHUS  POISONING;  IVY  POISON 
Contact  with  Rhus  toxicodendron  produces  in  many  people  a 
most  active  dermatitis.  There  is  marked  burning  with  considerable 
itching  of  the  involved  surface.  There  may  be  a  simple  erythema, 
but  usually  there  are  small  vesicles  and  bullae  filled  with  serum,  which, 
if  they  become  infected,  form  pustules  with  the  possibility  of  mul- 
tiple abscesses.  When  the  face  is  involved,  great  disfigurement 
may  result. 


FURUNCUMJSIS;    HOILS  4II 

I  have  used  various  measures  from  time  to  time  in  the  treat- 
ment of  this  form  of  dermatitis.  For  the  acute  stage — the  period 
of  itching,  burning,  and  edema — there  is  no  better  remedy  than 
the  fluidextract  of  (irindvlia  robusta — one  to  one  and  one-half 
drams  to  the  pint  of  water.  In  the  very  acute  cases  one  dram 
would  better  be  used  at  first.  It  is  best  apphed  on  Hnt  or  soft  old 
linen  as  a  wet  dressing.  The  solution  should  be  used  cold  and  re- 
newed every  fifteen  to  thirty  minutes.  During  the  stage  of  resolution 
a  saturated  solution  of  boric  acid  may  be  used  in  the  same  way,  or, 
what  is  more  convenient,  an  ointment  composed  of  5  percent* boric 
acid  in  ungt.  aquae  rosae.  This  is  applied  to  the  parts  on  linen, 
after  which  resolution  usually  takes  place  promptly.  When  pus- 
tules develop  they  must  be  opened  and  the  parts  treated  with  a 
wet  dressing  of  a  saturated  solution  of  boric  acid. 

FURUNCULOSISj  BOILS 

Boils  are  frequently  seen  in  delicate,  poorly  nourished  children, 
and  are  usually  due  to  the  inoculation  of  the  skin  with  the  staphy- 
lococcus. There  is  no  evidence  of  any  abnormal  constitutional 
state  other  than  malnutrition.  The  boils  occasionally  develop 
in  well  babies.  Under  proper  management  there  will  be  a  crop  or 
two,  but  perhaps  not  over  five  or  six  boils  in  all.  In  marasmic 
cases,  in  hospital  work,  I  have  opened  over  one  hundred  on  one 
patient  in  caring  for  the  successive  crops  as  they  appeared. 

Treatment. — Local. — When  pus  is  evident  in  the  boil,  a  free  in- 
cision should  be  made  and  the  pus  expressed.  The  skin  about  the 
wound  should  be  washed  vigorously  with  tincture  of  green  soap 
or  ordinary  soap  and  water.  Applying  a  few  drops  of  a  solu- 
tion of  bichlorid  of  mercury  is  of  little  or  no  value.  This  in 
itself  will  not  be  sufficient  to  prevent  a  reinfection;  as  some  pus 
invariably  escapes  upon  the  surrounding  healthy  skin  when  many 
boils  are  opened.  A  wet  disinfectant  dressing  or  a  disinfectant 
ointment  should  follow  incision  and  cleansing.  Bichlorid  dress- 
ings are  to  be  used  only  temporarily  in  children.  The  dressing 
which  has  appeared  best  to  prevent  the  spread  of  the  infection 
is  a  saturated  solution  of  boric  acid,  which  is  used  on  gauze  or 
lint,  when  the  involved  area  is  not  too  large.  In  a  marantic  child, 
when  a  considerable  portion  of  the  surface  over  the  trunk  or  thorax 
needs  to  be  covered,  the  repeated  renewal  of  the  solution  causes 
a  reduction  in  temperature  which  is  not  desirable.  In  such  infants, 
and  in  out-patient  work  where  a  wet  dressing  cannot  be  used,  an 
ointment  of  15  percent  boric  acid  in  vaselin  is  thickly  spread  on 
Hnt  and  applied  to  the  wound  and  for  a  considerable  distance  about 
it.  The  dressing  should  be  changed  every  six  hours.  Ichthyol 
is  of  little  service  when  used  in  a  strength  of  less  than  20  percent. 
The  odor  is  disagreeable,  it  stains  the  skin  and  the  clothing  and 


412  DISEASES    OF    THE    SKIN 

controls  the  condition  no  better  than  does  the  boric  acid  ointment. 
Another  advantage  is  that  the  latter  is  comparatively  inexpensive. 
With  fat  children,  who  sometimes  develop  boils  on  the  abraded 
surfaces  at  the  folds  of  the  neck  or  the  nates,  and  in  children  who 
perspire  freely,  I  have  used  a  dusting-powder  composed  as  follows: 

I^.      Pulveris  acidi  borici oj 

Pulveris  amyli 

Pulveris  zinci  oxidi aa   oiss 

M.     Sig. — Dusting-powder. 

This  is  applied  as  soon  as  the  wound  is  closed,  and  the  parts  are 
kept  dry  with  it. 

Constitutional. — The  constitutional  treatment  is  important.  If 
the  child  is  marasmic  or  if  he  has  malnutrition,  suggestions  found 
under  those  headings  should  be  brought  into  use.  In  the  many 
cases  I  have  treated,  internal  medication  other  than  that  directed 
toward  the  improvement  of  the  general  constitutional  condition 
has  been  without  value.  The  sulphid  of  calcium  and  other  drugs 
which  are  supposed  to  have  a  direct  influence  upon  the  condition 
have  proved  of  no  service.  They  were  not  considered  valueless 
because  the  patient  did  not  recover,  for  if  the  patient  is  not  too 
reduced  in  vitality  he  always  recovers,  regardless  of  the  treatment. 
Observation  on  a  series  of  cases  of  this  type  for  which  opportunity 
was  afforded  by  institution  work  has  shown  that  those  treated  with  the 
sulphid  of  calcium,  for  example,  made  no  greater  progress  than  did 
those  to  whom  it  was  not  given.  This  line  of  treatment  is  an  example 
of  "heredity  in  medicine."  A  remedy  has  been  advocated  by  some 
one  of  consequence  in  the  past.  It  is  then  handed  down  from  gen- 
eration to  generation  by  writers,  many  of  whom,  not  having  had 
opportunity  to  place  observations  of  value  behind  their  advocacy 
of  the  measure,  have  simply  repeated  what  has  been  said  by  others. 

No  matter  how  extensive  the  process,  children  with  furunculosis 
may  be  bathed  as  in  health.  The  water  used  for  the  bath  should 
first  be  boiled,  and  in  it  bicarbonate  of  soda,  one  tablespoonful 
to  the  gallon,  should  be  used.  Of  course,  there  should  be  little  or 
no  friction  of  the  skin. 

SCABIES;  ITCH 

Scabies  is  a  contagious  disease  of  the  skin  caused  by  the  bur- 
rowing of  the  acarus  scabiei.  The  disease  is  seen  with  considerable 
frequency  among  out-patient  children.  The  cases  differ  greatly 
in  severitv,  but,  in  all,  the  treatment  is  practically  the  same,  vary- 
ing only  as  to  the  necessity  of  repeating  or  continuing  it.  At  bed- 
time a  hot  bath  is  ordered,  from  105°  F.  to  110°  F.  While  in  the 
bath  the  patient  is  vigorously  scrubbed  with  a  towel,  using  the 
yellow  laundry  soap.  After  the  scrubbing  he  is  dried  vigorously 
and  sulphur  ointment,  U.  S.  P.,  is  rubbed  as  vigorously  into  the 
skin.  In  forty-eight  hours  the  process  is  repeated  and  again  repeated 
forty-eight  hours  later.     A  repetition  at  twenty-four-hour  intervals 


bed-sores;  decubitus,     pediculi 


413 


is  usually  too  irritating  to  the  skin.  The  third  treatment  usually 
terminates  the  case.  In  quite  young  children,  in  whom  the  sulphur 
ointment  may  be  too  irritating,  it  may  be  diluted  one-fourth  or  one- 
half  by  the  addition  of  vaselin.  This  may  be  done  with  older  chil- 
dren also  if  the  first  application  produces  considerable  dermatitis. 
Care  must  be  exercised  in  destroying,  boiling,  or  disinfecting  all 
clothing  previously  worn  by  the  patient. 


BED-SORES?  DECUBITUS 

During  any  illness  with  greatly  disturbed  nutrition,  as  in  cerebro- 
spinal meningitis,  typhoid  fever,  empyema,  or  in  any  prolonged 
illness  with  emaciation,  constant  pressure  on  the  prominent  bony 
parts  inteferes  sufficiently  with  the  circulation  to  cause  destruction 
of  the   integument.     The 

most    frequent    sites    for  ^ 

decubitus  in  children  are  /'  -«_ 

the  sacrum,  the  heels,  and 
the  back  of  the  head. 

The  condition  is  best 
prevented  by  cleanliness, 
both  as  to  the  patient  and 
the  bed  linen,  and  by 
keeping  the  latter  smooth 
and  frequently  changing 
the  position  of  the  patient. 
The  parts  as  they  become 
sensitive  and  show  redness 
should  be  bathed  several 
times  a  day  with  alcohol. 
If  this  does  not  relieve  the 
condition,  the  areas  should 
be  covered  with  diachylon 
plaster  so    as   completely 

to  cover  and  protect  the  involved  areas.     The    air-cushion  or   the 
water-bed  may  be  necessary  in  any  prolonged  illness. 

When  the  back  of  the  head  is  involved,  the  scalp  should  be 
shaved  and  the  head  allowed  to  lie  in  a  home-made  head-rest 
which  is  constructed  as  follows  (Fig.  43):  A  piece  of  fairly  stiff 
wrapping-paper,  four  inches  wide,  is  twisted  into  a  rope,  of  which 
a  circle  four  to  five  inches  in  diameter  is  made  by  bringing  the  ends 
together.  The  paper  is  then  wrapped  thickly  with  absorbent  cotton, 
which  is  in  turn  wrapped  with  a  two-inch  roller  bandage. 


Fig.  43.— Head-rest  to  Prevent  Bed-sores. 


PEDICULI 
Head  lice,  or  pediculi  capitis,  are  very  frequently  seen  in  out- 
patient and  hospital  work  among  children  in  all  the  larger  cities. 


414  DISEASES    OF   THE    SKIN 

Occasionally  children  become  infected  in  school  or  in  public  convey- 
ances, and  carry  the  vermin  to  other  members  of  the  family. 

The  most  successful  and  cleanly  treatment  consists  in  cutting  the 
hair  short;  this  done,  wash  the  head  with  soap  and  water  twice  a 
day,  and  after  drying  moisten  the  scalp  thoroughly  with  the  following 
solution,  daily: 

I^.      Acidi  acetici 5ij 

.4itheris  sulphurici 5  iij 

Tincturae  delphinii 

Spirit!  vini  rectificati aa  5iv 

Improvement  will  follow  a  few  treatments.  The  pediculi  will  be 
killed  and  the  nits  may  be  removed  with  a  line-tooth  comb.  If  the 
patient  is  a  girl,  it  is  not  absolutely  necessary  to  sacrifice  the  hair. 
It  may  be  parted  from  various  portions  of  the  scalp  and  the  solution 
appHed  without  previous  washing.  However,  if  the  hair  is  not  cut,  a 
much  longer  time  will  be  required  to  effect  a  cure. 

TINEA  TONSURANS;  RING-WORM  OF  THE  SCALP 
Ring-worm  of  the  scalp  due  to  the  action  of  the  trichophyton 
tonsurans  is  of  frequent  occurrence,  and  on  account  of  its  conta- 
gious nature  is  a  disease  greatly  dreaded  in  institutions  for  children. 
An  epidemic  once  started  is  only  with  the  greatest  difficulty  eradi- 
cated. The  appearance  of  the  scalp  is  characteristic.  Beginning 
with  a  few  small  vesicles,  the  process  extends  from  the  periphery 
outward,  showing  the  scaly  desquamating  scalp,  and  the  short  stubby 
hairs  broken  at  their  points  of  exit  from  the  scalp.  There  may  be 
but  one  area  involved  or  there  may  be  a  dozen.  I  have  seen  almost 
complete  baldness  result  from  the  coalescence  of  many  of  these 
areas. 

Treatment. — Cures  are  difficult  and  the  treatment  must  be  along 
radical  lines.  In  an  epidemic  several  years  ago  at  the  Country  Branch 
of  the  New  York  Infant  Asylum,  abundant  opportunity  was  offered 
to  test  various  measures  of  treatment  that  had  been  advocated  by 
different  observers.  Among  others  were  chrysarobin  in  various 
combinations,  carbolic  acid,  iodin,  bichlorid  of  mercury,  sulphur, 
and  white  precipitate.  As  a  result  of  much  experimentation,  a 
useful  scheme  of  management  was  established,  the  report  of  which 
may  be  found  in  "The  New  York  Medical  Journal,"  of  October  10, 
1891. 

The  location  of  the  fungus  in  the  hair-follicle  makes  it  very  diffi- 
cult to  apply  any  drug  so  that  it  will  be  effective  as  a  parasiticide. 
In  order  to  accompHsh  this,  it  is  absolutely  necessary  to  cut  the  hair 
of  the  entire  scalp  as  short  as  possible.  Upon  beginning  the  treat- 
ment the  scalp  is  thoroughly  scrubbed  with  soap  and  water,  using 
the  strongly  alkaline  yellow  laundry  soap  so  as  to  remove  all  the 
dead  hair  and  desquamated  epithelium.     The   parasiticide  to  be 


TINEA   tonsurans;    RING-WORM   OF   THE   SCALP  415 

used  is  then  rubbed  into  the  diseased  area  and  for  a  considerable 
distance  on  the  surrounding  heahhy  scalp.  The  parasiticide  which 
answered  best  with  us  was  composed  of  bichlorid  of  mercury  two 
grains  in  one-half  ounce  of  equal  parts  of  olive  oil  and  kerosene. 
The  bichlorid  must  be  dissolved  in  a  small  quantity  of  alcohol  before 
it  is  added  to  the  oil  mixture.  This  is  rubbed  into  the  diseased  area 
every  day  until  the  scalp  becomes  sore  and  tender.  In  order  to 
prevent  the  spread  of  the  infection  to  other  parts,  the  solution  may 
be  apphed  every  fourth  day,  without  friction,  to  the  entire  scalp.  It 
is  necessary  in  order  to  effect  a  prompt  cure  to  produce  a  dermatitis 
at  the  site  of  the  lesion.  When  this  occurs  the  treatment  is  tempo- 
rarily discontinued.  When  the  inflammation  subsides  another  is 
produced  in  like  manner.  After  three  or  four  weeks  of  this  treatment 
it  may  be  discontinued  and  the  parts  kept  under  observation  in 
order  to  note  the  results.  A  daily  application  of  sterile  oil  aids  in 
bringing  the  skin  to  a  normal  condition. 

In  one-third  of  the  children  in  the  epidemic  referred  to,  two  grains 
of  the  bichlorid  of  mercury  were  added  to  one  ounce  of  the  tincture 
of  iodin.  Twenty-six  cases  were  treated  by  this  method  with  an 
average  duration  of  treatment  of  eight  and  one-half  weeks.  Several 
recovered  in  four  weeks,  while  in  others  twelve  weeks  of  treatment 
were  necessary  before  it  could  be  discontinued.  While  the  treatment 
is  under  way  the  child  should  wear  a  cap,  day  and  night.  This  may 
be  made  of  any  cheap,  light-weight  material,  which  after  a  day  or 
two  of  use  may  be  burned.  Cheese-cloth  caps  were  used  in  our 
cases.  Rubber  gloves  were  necessary  to  protect  the  hands  of  the 
nurse  who  made  the  applications,  especially  if  there  were  many  heads 
to  be  treated. 

The  epidemic,  which  included  at  least  one  hundred  cases,  was 
controlled  by  the  above  means  and  prophylaxis  resulted  from  the 
use  of  the  kerosene  and  olive  oil  without  the  bichlorid.  It  was 
found  impossible  to  maintain  a  quarantine  permanently  or  effectu- 
ally even  for  a  short  time,  particularly  during  the  warmer  months, 
therefore  every  inmate  of  the  asylum  of  the  "runabout"  age  who 
did  not  have  the  disease  was  treated  as  though  he  was  expected  to 
get  it.  Every  head  was  "cUpped"  and  the  hair  kept  short.  Twice 
a  week  they  were  given  a  kerosene  and  olive  oil  shampoo. 

In  private  work  the  continued  use  of  kerosene  and  olive  oil  is  not 
popular  for  reasons  readily  understood.  In  such  cases  the  hair  is 
clipped  as  soon  as  the  case  is  diagnosed  and  a  kerosene  shampoo 
given.  The  bichlorid  of  mercury,  two  grains  to  one  ounce  of  tincture 
of  iodin,  U.  S.  P.,  is  applied  to  the  parts  with  sufficient  vigor  to 
produce  a  dermatitis.  If  the  disease  shows  a  tendency  to  spread  on 
the  scalp  beyond  the  original  site  it  is  best  prevented  by  the  use  of 
the  kerosene  and  olive  oil,  as  above  suggested. 


4l6  DISEASES   OF   THE   SKIN 


TINEA  CIRCINATA 
Ring- worm  is  produced  by  the  vegetable  parasite,  trichophyton. 
It  may  develop  upon  any  portion  of  the  skin  surface.  The  treat- 
ment is  the  use  of  some  irritant  that  will  produce  a  desquamation 
of  the  epidermis  in  the  superficial  layers  of  which  the  parasite  is 
located.  The  tincture  of  iodin  has  proved  a  satisfactory  remedy  if 
the  disease  is  located  where  its  use  is  possible.  Two  or  three 
applications  of  the  U.  S.  P.  tincture  is  all  the  treatment  that  is 
ordinarily  required.  If  the  case  is  at  all  obstinate,  two  grains  of 
bichlorid  of  mercury  may  be  added  to  the  ounce  of  the  tincture  of 
iodin.  If  the  lesion  is  situated  on  an  exposed  surface  such  as  the 
face,  five  grains  of  bichlorid  of  mercury  may  be  dissolved  in  equal 
parts  of  alcohol  and  glycerin  and  applied  locally. 

MILIARIA;  PRICKLY  HEAT 

In  prickly  heat  there  is  an  acute  engorgement  of  the  vessels  of 
the  sweat-glands  with  obstruction  of  their  outlets.  Minute  papules 
form  which  are  reddish  in  color.  The  mild  cases  are  without  inflam- 
mation. When  inflammation  develops,  small  vesicles  also  appear, 
and  may  cover  large  areas  of  the  body.  Nearly  every  infant  suffers 
from  prickly  heat  in  the  summer.  It  is  most  frequently  seen  on  the 
head  and  neck  and  over  the  chest  and  shoulders.  The  patients  are 
very  uncomfortable  and  restless.  There  is  evidently  a  great  deal 
of  burning  and  itching.  The  condition  is  caused  by  heat,  due  either 
to  too  much  clothing  or  to  the  hot  weather  of  summer;  both  causes 
may  be  operative.  I  have  frequently  seen  it  in  winter  in  overclad 
children.  Most  babies  are  overclad  at  all  seasons  of  the  year.  When 
prickly  heat  develops,  regardless  of  the  season,  it  is  a  sure  sign  that 
the  child  has  been  kept  too  warm.  The  duration  of  the  miliaria  is 
dependent  upon  climatic  conditions  and  also  upon  the  treatment.  I 
have  seen  cases  which  existed  for  months. 

Treatment. — Heavy  clothing  and  flannels  are  to  be  avoided.  In 
order  to  lessen  the  local  irritation,  the  garment  worn  next  to  the  skin 
may  be  lined  with  silk,  linen,  or  gauze.  The  further  means  of  manage- 
ment as  regards  both  the  relief  afforded  the  patient  and  the  cure  of 
the  condition,  consists  in  the  frequent  application  of  cool  water,  in 
the  form  either  of  a  tub-bath  or  sponging.  The  soda  bath,  the  bran 
bath,  and  the  starch  bath  (pp.  30,  31)  are  all  most  useful.  For  pur- 
poses of  sponging,  a  solution  of  bicarbonate  of  soda  should  be  used 
— one  tablespoonful  to  a  gallon  of  water.  The  relief  afforded  the 
patient  depends  not  so  much  upon  what  is  used  in  the  water  as  upon 
the  fact  that  plenty  of  cool  water  comes  in  contact  with  the  itching, 
burning  skin.  Ointments  and  salves  are  of  little  service  here,  as 
they  tend  to  produce  further  maceration  of  the  skin.     As  local  appli- 


miliaria;   prickly  heat  417 

cations,  powders  are  preferred  to  lotions.     A  powder  used  with  satis- 
faction in  this  condition  is  of  the  following  composition: 

I^.     Acidi  salicylatis gr.  x 

Acidi  borici gr.  Ix 

Pulveris  amyli 

Pulveris  zinci  oxidi aa    oj 

This  is  to  be  dusted  freely  over  the  involved  surface  several 
times  daily,  every  hour  if  necessary.  In  case  irritation  is  produced 
by  the  saHcylic  acid  it  may  be  omitted  or  its  strength  may  be  de- 
creased by  the  addition  of  powdered  starch. 


27 


DISEASES  OF  THE  EAR 

EARACHE 
In  every  case  of  earache  in  an  infant  or  young  child  the  ear-drum 
should  be  examined.  It' may  show  intense  congestion  and  bulging, 
requiring  immediate  incision,  or  there  may  be  but  slight  congestion 
about  the  periphery  of  the  drum  and  at  the  tip  of  the  malleus. 
When  the  latter  condition  exists  there  are  various  means  of  relieving 
the  pain,  the  most  effectual  appHcation  of  drugs  being  probably 
instillation  into  the  ear  of  equal  parts  of  a  4  percent  solution  of  cocain 
and  camphor-water;  five  drops  of  the  warm  solution  are  dropped 
into  the  ear  and  repeated  every  half  hour  if  necessary;  after  which 
dry  heat  may  be  appHed  by  the  use  of  a  hot-water  bottle  or  a  salt 
bag.  I  have  frequently  relieved  severe  attacks  of  earache  by  means 
of  a  hot-water  douche — one  pint  of  water  at  110°  F.,  using  a  douche- 
bag  or  a  fountain  syringe.  When  the  pain  is  not  promptly  relieved 
the  ear  should  be  carefully  watched,  particularly  if  there  are  recur- 
rent shooting  pains,  a  throbbing  sensation,  or  a  feeling  of  fullness 
in  the  ear.  In  young  children  a  rise  in  temperature  associated 
with  earache  is  often  indicative  of  an  acute  infectious  process  in 
the  middle  ear,  and,  in  addition  to  the  treatment  suggested,  the  ear 
should  frequently  be  examined,  in  order  to  be  prepared  for  early 
incision  of  the  drum  membrane  should  it  be  required. 

ACUTE  OTITIS 
Acute  otitis  rarely  occurs  in  infants  and  children  as  an  inde- 
pendent affection,  but  is  usually  a  complication  of,  or  a  sequela 
of  some  infectious  disease.  Among  my  own  patients  a  great  majority 
of  cases  occurred  in  association  with  or  following  an  acute  inflam- 
matory condition  of  the  upper  respiratory  tract  due  to  a  mixed 
infection — a  condition  which  occurs  in  many  of  the  illnesses  of 
infancy  and  early  childhood;  thus,  it  not  infrequently  follows 
simple  rhinitis,  pharyngitis,  tonsillitis,  grippe,  measles,  or  scarlet 
fever.  The  disease  is  of  much  more  frequent  occurrence  in  children 
than  in  adults.  The  younger  the  child,  the  greater  the  apparent 
susceptibility.  This  susceptibility  in  the  young  is  due  chiefly  to 
three  causes:  the  comparatively  patent  eustachian  tube,  the  ten- 
dency to  inflammatory  conditions  of  the  throat,  and  the  presence 
of  adenoid  growths  in  the  pharyngeal  vault — features  favorable 
to  the  development  of  infection  and  for  its  extension  to  the  cavity 
of  the  middle  ear. 

418 


acute;  otitis  419 

Otitis  in  young  children  is  probably  more  frequently  overlooked 
by  the  practitioner  than  is  any  other  disease  of  childhood.  This 
is  through  no  fault  of  his  own;  it  is  because  of  its  indefinite  mani- 
festations, and  the  faulty  teachings  of  text-books  as  to  the  symp- 
tomatology of  the  disease.  In  a  search  of  many  works  on  otology, 
I  find  that  the  symptoms  as  laid  down  are  dependent  almost  ex- 
clusively upon  evidences  of  pain — earache — the  pain  being  com- 
plained of  by  older  children  or  manifested  in  the  very  young  by 
vigorous  crying,  by  tossing  the  head  from  side  to  side,  by  head- 
rolling,  ear-tugging,  crying  out  in  sleep,  disinclination  to  rest  the 
head  on  the  affected  side,  pain  upon  manipulation  of  the  ear — in 
short,  we  have  been  taught  that  there  is  invariably  some  manifesta- 
tion of  pain  referable  to  the  ear  or  the  adjacent  structures  in  all 
cases  of  acute  otitis  in  infants  and  young  children. 

Illustrative  Cases. — What  symptom  is  most  frequently  associated 
with  otitis  in  children?  In  seventy-two  private  cases  one  symptom, 
and  only  one,  was  present  in  all — fever.  The  otitis  was  apparently 
primary  in  three.  In  these  the  condition  did  not  follow  and  was  not 
associated  with  any  previous  abnormal  state,  as  far  as  we  were  able 
to  judge.  One  was  associated  with  or  followed  German  measles ;  two, 
scarlet  fever;  seven,  measles;  and  fifty-eight,  grippe  or  catarrhal 
colds.  In  the  cases  in  which  the  otitis  followed,  but  was  not  immedi- 
ately associated  with  any  of  the  preceding  diseases,  which  was  the  rule 
in  the  majority  of  the  cases,  there  was  nothing  especially  character- 
istic in  the  temperature  range.  In  some  there  were  the  morning 
drop  and  the  evening  rise ;  in  the  others  tTiere  was  no  regularity  as 
regards  the  temperature  range.  With  but  few  exceptions  the 
otitis  developed  during  convalescence  from  an  acute  process  else- 
where, the  ear  involvement  being  suspected  because  of  a  persistent 
elevation  of  the  temperature  for  which  no  other  cause  could  be 
discovered.  The  fact  that  fifty-eight  of  the  cases,  or  81.5  percent, 
occurred  with  or  followed  non-specific,  inflammatory  conditions  of 
the  upper  respiratory  tract,  such  as  tonsillitis,  grippe,  and  catarrhal 
colds,  emphasizes  the  necessity  for  frequent  aural  examinations 
during  or  following  such  disorders,  particularly  when  there  is  an 
elevation  of  the  temperature — a  temperature  which,  in  the  absence 
of  definite  clinical  signs,  we  are  apt  possibly  to  attribute  to  chronic 
grippe,  malaria,  typhoid  fever,  or  dentition. 

The  most  interesting  factor  in  this  series  of  cases  was  the  absence 
of  pain  or  localized  tenderness  on  manipulation  in  fifty  of  the  cases, 
or  69  percent.  Among  those  included  in  the  pain  group,  twenty- 
two  in  number,  there  are  some  which  perhaps  should  not  be  so 
included.  In  these  there  were  no  signs  of  pain,  as  we  generally 
expect  to  find  it;  but  in  this  group  are  included  those  who  were 
very  restless,  who  slept  poorly,  and  those  who  showed  evidence  of 
any  great  discomfort.     Upon  discovering  the  ear  disease  and  noting 


420 


DISEASES  OF  THE   EAR 


the  relief  which  followed  incision  of  the  drum  membrane,  it  was 
fair  to  assume  that  the  source  of  the  previous  discomfort  was  the 
ear.  Had  we  depended  for  the  usual  signs  of  pain  or  local  tenderness, 
in  fifty  of  the  cases  a  diagnosis  of  otitis  at  the  time  would  have  been 
impossible.  Six  were  seen  in  consultation,  because  of  the  unex- 
plained, continued  fever.  Nine  had  been  treated  by  other  physicians 
who  had  failed  to  discover  the  cause  of  the  continued  fever.     In 


Fig.  44.— Hard-rubber  Ear  Syringe. 


none  of  these  had  ear  involvement  been  suspected,  because  of  the 
absence  of  pain  and  localized  signs. 

Treatment. — Operative. — Every  practitioner  who  has  children  for 
his  patients  should  be  sufficiently  familiar  with  the  landmarks  of  the 
normal  drum  membrane  at  the  various  ages  of  early  life  to  differen- 
tiate the  normal  from  the  abnormal.  In  the  routine  examination  of 
the  child,  the  ear  should  be  included  in  all 
conditions  associated  with  angina  or  fever. 
In  quite  young  babies  an  otoscopic  examina- 
tion may  show  a  dull  whitish-appearing  drum 
membrane  which  on  a  superficial  examination 
of  the  case  might  be  ignored.  In  all  cases, 
particularly  at  this  age,  when  the  drum  land- 
marks are  indistinct,  a  cotton-pointed  probe 
should  be  brushed  over  the  surface,  thus  re- 
moving the  epithelial  scales  which  may  have 
lodged  there,  when  perhaps  a  congested,  bulg- 
ing membrane  may  be  revealed.  This  point 
was  brought  out  by  Dr.  J.  F.  McKernon 
in  January,  1899,  in  a  discussion  before  the 
State  Medical  Society  at  Albany. 

Conditions  or  appearances  of  the  drum 
membrane  which  require  incision  are  often 
difficult  of  recognition  by  those  not  skilled  in 
otoscopy.  When  the  drum  is  bulging,  deeply 
congested  in  appearance,  with  landmarks  indistinct,  an  incision  is 
necessary,  and  should  be  made  in  the  posterior  quadrant,  beginning 
low  down  and  extending  upward  through  Shrapnell's  membrane. 
When  also  there  is  congestion  of  the  drum  membrane  over  the  tubal 
entrance,  w^hen  the  congestion  extends  toward  the  periphery  with 
indistinct  landmarks  without  bulging,  incision  is  indicated. 

Post-operative. — The  after-treatment  following  incision  consists  in 


ACUTE   OTITIS  421 

syringing  the  ear  at  three-hour  intervals  with  eight  ounces  of  a 
I  :  10,000  solution  of  bichlorid  of  mercury  for  three  or  four  days,  when 
the  syringing  may  usually  be  practised  at  intervals  of  from  four  to 
five  hours  until  the  drum  closes.  In  very  young  infants  if  the  bi- 
chlorid causes  a  dermatitis  at  the  meatus,  it  is  well  to  change  to  a 
sterile  normal  salt  solution,  using  the  same  quantity  of  fluid.  In 
those  cases  in  which  only  serum  is  present  at  the  time  of  operation, 
a  closure  in  ten  days  may  be  expected ;  if,  however,  pus  is  present, 
from  two  to  three  weeks  will  be  required.  A  sudden  stopping  of 
the  discharge  usually  means  that  the  opening  in  the  drum  is  closed, 


^^ 


A?5*''/ 


Fig.  46.— Syringing  the  Ear. 

either  through  plugging  of  the  opening  with  thick  pus  or  because 
of  the  too  early  heaUng  of  the  drum:  in  either  event  a  reestablish- 
ment  of  the  discharge  is  required  by  removing  the  obstruction  or 
by  reincision.  The  chief  factors  in  prolonging  the  discharge  are 
adenoids  and  a  lowered  state  of  physical  resistance.  After  syring- 
ing, the  ear  should  be  carefully  dried  with  absorbent  cotton.  For 
purposes  of  syringing,  a  one-ounce  hard-rubber  ear  syringe  with 
soft-rubber  tip  (Fig.  44)  answers  best.  If  this  is  not  obtainable  a 
douche-bag,  at  an  elevation  of  not  more  than  three  feet  above  the 
patient's  head,  may  be  used.  The  douche-bag  sometimes  answers 
better  for  those  who  are  unskilled,  or  a  soft-rubber  bulb  syringe  of  a 
capacity  of  one  to  two  ounces  may  be  used  (Fig.  45).     With  either 


422  DISEASES    OF    THE    EAR 

method,  the  child  rests  on  his  back  with  his  hands  pinned  to  his 
side  by  means  of  a  large  bath  towel,  with  a  pus  basin  under  the  ear 
to  catch  the  flow  (Fig.  46).  If  the  nurse  can  have  an  assistant  the 
upright  position  may  be  used. 

DEAFNESS 

Hearing  is  probably  established  in  the  newly  born  during  the 
first  two  or  three  days  of  life.  During  the  early  months  of  life 
the  hearing  is  very  acute.  Acquired  deafness  is  not  at  all  unusual, 
however,  even  in  comparatively  young  children.  Among  its  most 
frequent  causes  is  an  extension  of  an  inflammation  from  the  throat 
to  the  tubal  mucous  membrane.  In  diphtheria,  in  the  exanthe- 
mata, in  grippe,  in  tonsillitis,  and  in  many  other  ailments  of  early 
life,  there  is  an  associated  inflammation  of  the  nasopharyngeal 
structures.  Unless  infection  of  the  middle  ear  occurs,  deafness 
is  usually  of  a  very  temporary  nature.  Persistent  deafness  may 
be  the  result  of  enlarged  tonsils,  adenoids,  or  organized  changes 
in  the  canal  or  in  the  middle  ear.  Among  the  most  frequent  causes 
of  persistent  deafness  in  children  are  adenoids  and  scarlet  fever. 
Deafness  at  rare  intervals  follows  an  attack  of  mumps  and  is  due 
to  an  involvement  of  the  labyrinth,  and  calls  for  expert  otologic 
treatment. 

Deaf  children  whose  condition  is  not  recognized  are  often  accused 
of  inattention  and  punished  when  they  are  slow  in  responding  when 
spoken  to.  They  make  slow  progress  in  school  and  are  considered 
stupid.  Many  such  children  show  defective  hearing  of  a  pronounced 
type,  due  usually  to  enlarged  tonsils  and  adenoids. 

The  management  in  these  cases  is  to  remove  the  adenoids  and 
tonsils.  When  relief  is  not  afforded  by  operation,  the  child  should 
be  taken  to  an  aurist  for  a  careful  examination  as  to  the  condition 
of  the  ears  and  the  hearing  capacity. 

CHRONIC  SUPPURATIVE  OTITIS 
Not  infrequently  cases  come  under  our  care  in  which  there  is  a 
purulent  discharge  from  the  ears,  oftentimes  most  offensive,  with 
a  history  that  the  discharge  followed  measles,  scarlet  fever,  or  grippe, 
and  that  it  has  continued  for  weeks  or  months.  Examination  may 
show  a  perforation  of  the  upper  portion  of  the  drum,  through  which 
there  is  a  free  discharge,  but  on  account  of  the  site  of  the  perfora- 
tion not  sulflcient  to  drain  completely  the  middle-ear  cavity;  or 
there  may  be  only  a  small  perforation,  too  low  for  effective  drainage. 
In  either  case  incision  should  be  made  and  free  drainage  established. 
The  ear  should  then  be  syringed  (Fig.  46)  at  least  three  times  a  day 
with  a  I  :  10,000  bichlorid  solution.  In  cases  of  chronic  suppurative 
otitis  it  is  well  to  examine  for  adenoids,  as  these  growths  in  the 
nasopharyngeal  vault  will  help  to  keep  up  the  discharge  indefinitely. 


MASTOIDITIS  423 

The  presence  of  dead  bone  and  granulations  is  also  to  be  considered 
in  the  chronic  suppurative  cases,  and  the  examination  is  not  com- 
plete until  the  condition  of  the  nasopharyngeal  vault  is  determined. 
When  the  presence  of  dead  bone  or  granulations  is  established,  it 
calls  for  radical  operative  procedures  by  a  skilled  otologist  in  order 
to  avoid  mastoid  and  intracranial  complications. 

MASTOIDITIS 
It  is  not  necessary  to  wait  for  swelling  in  the  post-auricular 
region,  or  pain  or  tenderness  over  the  mastoid  in  order  to  make 
a  diagnosis  of  mastoid  disease.  The  child  may  object  quite  as 
strongly  to  pressure  on  the  unaffected  side  or  to  pressure  elsewhere 
on  the  skull,  which  completely  negatives  what  one  might  hope  to 
elicit  by  tenderness.  Involvement  of  the  mastoid  cells  may  be 
looked  for  in  any  case  in  which  there  is  pus  in  the  middle  ear.  A 
daily  elevation  of  the  temperature  in  purulent  otitis  with  a  freely 
discharging  ear  is  very  suggestive  of  mastoiditis,  particularly  if 
there  is  no  other  readily  assignable  cause  for  the  fever.  The  further 
signs,  continued  fever  with  prolapse  of  the  posterior  superior  wall 
of  the  canal,  with  the  canal  rapidly  filling  with  pus  after  syringing, 
mean  that  mastoiditis  is  almost  sure  to  be  present  and  operation 
is  indicated.  With  tumefaction  and  swelHng  of  the  soft  parts  be- 
hind the  ear — the  so-called  perimastoiditis — the  mastoid  cells  and 
antrum  will  almost  invariably  be  found  involved  and  the  radical 
mastoid  operation  should  be  performed. 


GLANDULAR  DISEASES 

ACUTE  ADENITIS 
The  management  of  acute  adenitis  in  a  child  depends  to  a  cer- 
tain extent  upon  the  age  of  the  child  and  the  factors  producing 
the  adenitis.  One  thing  is  to  be  remembered,  however,  in  the 
treatment.  It  is  this:  The  constant  application  of  an  ice-bag  will 
do  more  toward  controlling  the  adenitis  and  preventing  complica- 
tions than  will  any  other  measure  which  we  possess.  Unfortunately, 
in  infants  and  in  a  few  young  children,  it  is  not  practicable,  being 
particularly  difficult  when,  as  is  generally  the  case,  the  cervical 
glands  are  involved,  since  it  is  then  almost  impossible  to  keep  the 
ice-bag  in  place.  In  older  children,  after  the  second  year,  it  should 
be  applied  continuously  day  and  night.  Where  ice  cannot  be  used, 
I  apply  the  cataplasma  kaoHni  as  follows:  A  piece  of  linen,  suffi- 
ciently large  to  cover  the  swollen  area,  is  thickly  covered  with  the 
paste  and  applied  to  the  parts.  A  fresh  application  should  be 
made  every  six  hours,  or  the  following  ointment  may  be  used: 

I^.     Ichthyoli oiiss 

Unguenti  zinci  oxidi q.  s.  ad  oj 

The  ointment  is  applied  freely  on  linen,  which  is  covered  with 
oiled  silk  and  held  in  position  by  a  suitable  bandage.  Many  mothers 
find  it  more  convenient  to  use  a  cap  made  of  cheese-cloth,  which 
covers  the  dressing  and  holds  it  in  place.  The  ichthyol  ointment 
should  be  freshly  applied  every  six  hours.  In  cases  where  other 
measures  have  been  unsatisfactory,  I  have  used  successfully  Crede's 
ointment,  fifteen  grains  of  which  are  rubbed  into  the  swollen  areas 
twice  daily. 

Not  only  is  it  necessary  to  treat  adenitis  locally,  but  the  source 
of  the  infection  must  be  sought  for  and  if  possible  eradicated.  In 
cervical  adenitis  the  source  of  the  infection  is  in  the  mouth  or  in 
the  throat.  Decayed  teeth,  enlarged  tonsils,  and  adenoids  will  prob- 
ably require  attention.  So  also  acute  tonsilHtis  and  diphtheria,  the 
anginas  of  grippe  and  the  exanthemata,  are  conditions  any  one  of 
which  may  cause  cervical  adenitis,  which  is  usually  due  to  a  mixed 
infection.  The  majority  of  my  cases  which  have  gone  on  to  suppura- 
tion have  been  either  a  pure  streptococcus  infection  or  the  strepto- 
coccus was  the  most  prominent.  Such  infections  may  take  place 
with  any  of  the  acute  infectious  diseases,  but  they  are  most  frequently 
met  with  in  scarlet  fever.  In  inguinal  adenitis,  balanitis  in  boys  or 
vulvovaginitis  in  girls  is  usually  the  source  of  the  infection. 

424 


PERSISTENT   ADENITIS  425 

Even  when  the  ice-bag  is  appUed  with  the  first  suggestion  of 
swelHng  and  used  faithfully,  the  cases  of  streptococcus  infection 
sometimes  go  on  to  suppuration.  Repeatedly  I  have  seen  the  aden- 
itis, which  is  often  an  early  compHcation  of  diphtheria,  disappear 
quickly  after  full  doses  of  diphtheria  antitoxin.  Acute  adenitis  ter- 
minates in  one  of  three  ways — resolution,  suppuration,  or  persistent 
adenitis.  When  the  swelling  softens,  we  know  that  suppuration  has 
taken  place,  and  our  only  treatment  is  to  incise  freely,  allowing  the 
pus  to  escape,  and  place  in  the  wound  a  strip  of  sterilized  gauze 
to  assist  in  drainage  and  to  prevent  too  early  a  closure  of  the  incision. 
The  wound  should  be  dressed  once  daily.  Extirpation  of  the  dis- 
eased gland  is  not  to  be  advised  until  later,  if  at  all. 

PERSISTENT  ADENITIS 

After  an  acute  adenitis,  in  a  small  percentage  of  cases,  the  gland 
or  glands  will  remain  persistently  enlarged,  so  as  to  constitute  a  defor- 
mity, or  the  deformity  may  be  the  result  of  a  series  of  acute  attacks, 
each  leaving  the  gland  a  Httle  larger  than  before.  Whether  these 
glands  are  tuberculous  from  the  outset  or  become  so  later,  it  is  im- 
possible to  state.  I  know,  however,  from  an  observation  of  several 
cases,  that  many  of  those  which  do  not  show  the  distinctive  character- 
istics of  tuberculous  adenitis  which  we  have  been  taught  to  expect,  do 
show  that  they  are  tuberculous  upon  examination  after  operation — 
the  glands  having  been  removed  because  of  the  unsightly  deformity; 
I  have,  therefore,  come  to  look  upon  pronounced  persistent  adenitis 
as  probably  of  tuberculous  origin,  even  though  but  two  or  three 
glands  appear  to  be  involved.  Because  these  chronically  enlarged 
glands  sometimes  undergo  resolution  without  suppuration  does  not 
prove  the  absence  of  tubercle  bacilH. 

Treatment. — I  have  treated  these  cases  of  persistent  adenitis  with 
electricity,  massage,  drugs,  and  local  applications,  but  am  unable  to 
advise  the  use  of  any  one  of  them,  nor  have  the  iodids  in  my  hands 
been  of  any  appreciable  value.  Constitutional  means,  of  course, 
should  be  employed — iron,  cod-liver  oil,  and  the  hypophosphites 
being  prescribed  if  the  child's  condition  appears  to  require  them.  In 
many  cases,  however,  such  treatment  is  not  called  for,  as  the  chil- 
dren are  in  perfect  condition,  the  process  being  entirely  a  local  one. 
I  have  had  no  experience  with  the  "x-ray"  and  various  "light" 
methods  of  treatment  which  are  advocated  by  some  writers.  My 
own  observation  in  the  management  of  these  cases  has  been  that 
when  the  glands  remain  for  several  weeks  sufficiently  large  to  pro- 
duce a  deformity,  removal  by  surgical  means  is  the  onlv  course  to 
pursue.  The  operation  is  a  simple  one,  is  quickly  performed,  and 
need  leave  but  a  very  slight  scar. 


426  GLANDULAR    DISEASES 


ADENOIDS 

By  the  term  "adenoids"  is  understood  a  hypertrophy  of  the 
mucous  glands  of  the  nasopharyngeal  vault.  They  may  be  associated 
with  an  enlargement  of  the  tonsils,  or  be  entirely  independent  of  it. 

The  growths  vary  in  consistency  from  friable,  sponge-like  tissue 
filled  with  blood,  to  those  composed  largel}^  of  firm  connective 
tissue.  The  age  of  the  child  appears  to  exert  but  little  influ- 
ence upon  the  character  of  the  growth.  I  have  removed  hard, 
firmly  organized  growths  from  children  of  eighteen  months  and  two 
years,  and  soft,  sponge-like  masses  from  children  seven  or  eight 
years  of  age.  The  amount  of  growth  varies  also,  from  a  slight 
fringe  of  hypertrophied  glands  situated  high  up  on  the  posterior 
pharyngeal  wall,  to  a  large  mass  which  completely  fills  the  naso- 
pharyngeal vault. 

Adenoids  may  occur  at  any  age,  but  are  more  common  in  children 
from  two  to  six  years  of  age.  The  youngest  case  I  have  operated  on 
was  six  months  of  age.  Cases  of  congenital  adenoids  have  been  re- 
ported. Some  children  have  large,  roomy,  nasopharyngeal  vaults; 
while  in  others,  on  account  of  the  high  palatal  arch  and  the  promi- 
nence of  the  bodies  of  the  cervical  vertebrae,  the  space  is  very  small. 
In  such  cases  a  very  small  amount  of  adenoid  tissue  causes  marked 
obstruction. 

The  symptoms  vary  according  to  the  character  and  the  amount 
of  the  growth.  With  a  small  growth  in  a  roomy  vault,  there  is  apt 
to  be  a  history  of  a  nasal  discharge  which  is  usually  regarded  as  a 
chronic  "  cold."  Many  of  these  cases  with  a  small  amount  of  actively 
secreting  adenoid  tissue  have  most  persistent  coughs  (page  255) ,  which 
are  worse  w^hen  the  child  lies  down.  There  may  be  nothing  more  than 
a  clearing  of  the  throat ;  usually,  however,  the  cough  is  more  or  less 
persistent.  Now  and  then  it  is  paroxysmal,  and  so  closely  resembles 
whooping-cough  that  an  error  in  diagnosis  is  often  made.  Such 
cases  oftentimes  pass  unrecognized.  The  presence  of  adenoids  is 
not  suspected  because  breathing  is  unobstructed,  the  cough  being 
attributed  to  the  stomach,  to  dentition,  to  nervousness,  etc.  When 
there  is  a  decided  obstruction  to  breathing,  whether  due  to  a  large 
growth  or  to  a  small  palatal  vault,  the  characteristic  signs  are  sure 
to  be  present:  The  open  mouth,  the  snoring  at  night,  the  stupid 
expression,  the  disturbed  articulation,  the  persistent  nasal  dis- 
charge, the  deafness,  the  inability  to  blow  the  nose,  the  cough, 
and  the  story  of  chronicity, — all  combine  to  make  a  picture  which 
can  be  produced  by  no  other  condition.  No  special  class  or  type 
of  child  is  affected.  We  find  adenoids  not  only  in  the  delicate  and 
ailing,  but  also  in  the  strong  and  well.  Out  of  hundreds  of  cases, 
I  have  seen  very  few  in  which  lymphatism  could  be  accused  of 
having  any  part  in  the  production  of  the  growths. 


ADENOIDS  427 

When  to  Operate. — The  management  is  operative  in  every  case 
in  which  the  growth  produces  symptoms  which  compromise  the  heakh 
and  comfort  of  the  patient.  Early  infancy  is  no  contraindication  to 
operation,  if  the  conditions  are  sufficiently  urgent,  h'ortunately,  the 
necessity  for  a  radical  operation  in  the  very  young,  that  is,  in  those 
under  one  year  of  age,  is  extremely  rare.  These  httle  patients,  how- 
ever, may  have  growths  sufficient  to  cause  an  obstruction,  which 
gives  rise  to  mouth-breathing,  to  difficulty  in  nursing,  and  to  a  very 
annoying  and  persistent  nasal  discharge. 

Operation  for  Temporary  Relief. — In  several  instances  I  have 
relieved  these  cases  temporarily  by  crushing  the  growths  with  the 
clean  index-finger.  At  this  age  the  adenoid  tissue  is  usually  very  soft 
and  friable.  The  finger-nail  should  be  cut  very  short  and  the  whole 
hand  thoroughly  scrubbed  and  disinfected.  The  child  is  wrapped 
and  pinned,  usually  in  a  large  towel,  so  that  the  arms  are  confined 
to  its  sides,  and  is  then  placed  on  its  back  on  the  bed  or  table.  A 
clean  towel  for  wiping  away  the  blood  should  be  placed  under  the 
head.  The  mother  and  nurse  should  be  advised  that  a  slight  bleed- 
ing is  expected.  With  the  child  thus  in  position,  the  physician 
holds  the  mouth  open  with  a  spoon  or  tongue  depressor,  and  passes 
the  clean  index-finger  of  the  right  hand  backward  into  the  vault 
and  easily  breaks  up  the  soft,  spongy  growth  which  may  be  present. 
The  adenoids  are  by  no  means  removed  by  this  method,  but  their 
continuity  is  destroyed  and  portions  of  the  growth  doubtless  slough 
off",  thus  affording  temporary  relief.  The  child  will  be  able  to  nurse 
without  inconvenience  and  the  nasal  discharge  will  stop.  Opera- 
tion, however,  is  thus  only  deferred  until  the  patient  is  older.  In  six 
months  or  a  year  the  symptoms  will  return. 

Operation  for  Permanent  Relief. — The  only  permanent  relief  lies 
in  a  curettage  of  the  vault,  and  even  with  a  complete  removal  of  the 
growth  by  curettage  and  forceps,  there  may  be  a  return  if  the  opera- 
tion is  performed  on  the  very  young — those  under  two  years  of 
age.  When  asked  by  parents  if  there  is  danger  of  a  return  of 
the  growth,  I  always  reply  that  a  return  is  possible,  and  always 
takes  place  in  a  small  percentage  of  the  cases.  The  older  the  child 
at  the  time  of  the  operation,  the  less  the  liability  of  a  recurrence. 
The  possibility  or  probability  of  a  return  is  no  argument  against 
the  removal  of  the  growths  in  the  very  young,  for  by  the  time  the 
child  is  three  or  four  years  of  age,  a  great  deal  of  permanent  harm 
may  have  resulted. 

As  operation  is  the  only  method  of  treatment,  it  is  one  with 
which  the  general  practitioner  should  by  all  means  familiarize  him- 
self. The  operation  is  not  performed  by  all  ahke.  Some  prefer 
the  sitting  position  without  an  anesthetic ;  others  employ  anesthesia 
and  raise  the  patient  to  a  sitting  position  at  the  time  of  the  opera- 
tion.    It  is  my  opinion  that  an  anesthetic  should  be  used  in  every 


428 


GLANDULAR   DISEASES 


case,  unless  contraindicated  by  some  such  condition  as  lymphatism  or 
cardiac  or  kidney  disease,  which  might  make  the  anesthesia  danger- 
ous. Regarding  the  choice  of  an  anesthetic,  my  preference  is  to  give 
nitrous  oxid  gas  in  children  over  two  years  of  age  to  produce  uncon- 
sciousness, and  then  substitute  ether.  This  method  is  far  more 
agreeable  to  the  patient  than  when  ether  is  used  from  the  beginning. 
Primary  anesthesia  is  all  that  is  required.  In  the  very  young, 
when  gas  is  not  permissible  on  account  of  producing  cyanosis, 
ether  alone  may  be  used.  Chloroform  I  have  learned  to  regard 
with  much  distrust.  A  boy  three  years  of  age  upon  whom  I  was 
to  operate  for  adenoids  came  near  dying  under  chloroform  anes- 
thesia ;  resuscitation  was  almost  despaired  of.  With  another  child  I 
had  a  similar  experience.  I  have  never  experienced  any  unpleasant 
effects  from  ether  during  these  operations. 


Fig.  47.— Position  for  Adenectomy  and  Tonsillotomy. 


If  the  operation  is  to  be  performed  without  an  anesthetic  the 
upright  position  is  the  best.  The  child's  arms  are  bound  to  its 
sides  with  a  large  tow^l  and  fastened  with  safety-pins.  He  should 
be  held  on  the  lap  on  the  right  side  of  an  attendant,  who  by  cross- 
ing his  legs  confines  the  legs  of  the  patient  between  his  own.  The 
attendant's  right  arm  encircles  the  child  while  the  left  controls 
the  head,  which  rests  against  his  right  shoulder.  A  basin  should 
be  within  reach  of  the  attendant,  as  the  bleeding  is  sudden  and 
profuse. 

If  an  anesthetic  is  used  the  child  is  placed  on  the  table  (Fig.  47) 
with  the  arms  bound  to  its  sides  by  a  large  towel  or  sheet.  The 
Denhardt  gag  of  the  O'Dwyer  intubation  set  is  used  to  keep  the 
jaws  open.     The  growth  should  be  located  with  the  finger,  and  any 


RETROPHARYNGEAL   ADENITIS  429 

adhesions  which  may  be  present  should  be  broken  up.  If  the  tonsils 
are  to  be  removed,  that  should  first  be  done.  As  soon  as  the  adenoids 
are  removed,  the  patient  is  turned  on  his  side  so  that  the  blood  can 
drain  into  a  basin  which  should  be  in  readiness  on  a  chair  at  the 
side  of  the  operating  table.  Before  removing  the  gag  the  operator 
should  pass  his  finger  into  the  vault  to  determine  if  it  is  clear;  if 
not,  the  curet  must  again  be  brought  into  use.  The  Knight  or 
McAuliffe  forceps  may  be  utilized  in  removing  any  shreds  of  tissue 
which  may  have  been  left  behind.  Two  curets  are  usually  necessary, 
a  small  and  a  larger  one  (Figs.  48  and  49).  The  operation  can  be 
more  successfully  performed  if  a  curet  is  used  in  which  the  blade 
stands  at  an  angle,  as  represented  by  the  drawings.  This  allows  a 
greater  play  of  the  cutting-blade  in  the  vault.  A  moderate  amount 
of  blood  is  swallowed,  which  is  usually  vomited  in  the  course  of  an 
hour  or  so.  Parents  should  be  told  that  this  may  occur.  The  child 
should  be  kept  in  bed  for  the  remainder  of  the  day  on  a  reduced 


C 


Figs.  48  and  49. — Adenoid  Curets. 

diet  of  diluted  milk,  broths,  and  gruel.  It  is  my  custom  to  allow, 
four  hours  after  the  operation,  three  ounces  of  milk  diluted  with 
three  ounces  of  water.  A  swallow  of  cold  water  or  pieces  of  cracked 
ice  can  be  given  at  any  time.  Following  the  operation  I  order 
for  the  nose  an  albolene  spray,  to  be  used  three  times  daily  for  three 
weeks. 

Three  months  after  the  operation  the  mother  is  asked  to  return 
with  the  child  for  examination.  In  several  instances  I  have  found 
that  fresh  adhesions  had  formed  between  the  cut  surfaces  and  the 
soft  palate,  which  had  caused  a  return  of  some  of  the  original 
symptoms.  These  adhesions  are  readily  broken  up  with  the 
finger,  as  are  also  any  recurring  growths  which  occasionally  may  be 
found. 

RETROPHARYNGEAL  ADENITIS 
Retropharyngeal  adenitis,  as  the  name  implies,  is  an  inflamma- 
tion of  one  or  more  of  the  glands  which  are  situated  posterior  to  the 
pharynx  between  the  pharyngeal  and  prevertebral  muscles.     Pain 


430  GLANDULAR    DISEASES 

and  difficulty  in  swallowing  are  always  present.  Other  symptoms 
are  fever, — ioo°  to  103°  F., — and  loss  of  appetite.  The  glands,  as  a 
rule,  suppurate,  forming  a  retropharyngeal  abscess  (see  page  242). 
In  an  acute  case  an  inspection  of  the  throat  will  usually  show  a 
swelling  at  the  right  of  the  median  line.  If  situated  low  down  on 
the  posterior  pharyngeal  wall,  it  may  escape  detection.  Upon  digital 
examination,  instead  of  a  smooth,  flat  surface,  the  finger  encounters 
an  elevated,  rounded  mass,  which  should  not  be  mistaken  for  an 
unduly  prominent  cervical  vertebra. 

In  retropharyngeal  adenitis,  while  suppuration  is  the  rule,  it 
does  not  invariably  follow.  In  one  case,  in  a  baby  six  months  old, 
we  waited  for  several  days  for  the  suppuration  of  the  gland,  which 
was  greatly  enlarged.     This  it  failed  to  do,  and  the  child  recovered. 

In  these  cases  treatment  must  be  both  local  and  constitutional. 
Local  treatment  consists  in  cleanliness.  The  mouth  should  be 
washed  with  a  saturated  solution  of  boric  acid  after  each  feeding. 
The  use  of  iodids  in  adenitis  in  children  I  have  found  of  questionable 
service.  More  is  accomplished  by  a  suitable  diet  and  plenty  of 
fresh  air. 

TUBERCULOUS  ADENITIS 

The  onlv  management  of  tuberculous  adenitis  which  should 
be  entertained  is  surgical — the  removal  of  the  diseased  glands. 
After  the  operation  the  child  should,  if  possible,  be  given  the  advan- 
tage of  an  outdoor  life  in  the  country,  inland.  These  cases  appear 
to  improve  most  rapidly  at  an  elevation  of  eight  hundred  feet  or 
more.  The  diet  should  consist  of  meat,  eggs,  milk,  and  of  high- 
proteid  cereals,  such  as  oatmeal  and  the  dried  legumes,  given  in 
the  form  of  purees.  It  is  my  custom  to  order  cod-liver  oil  and  malt 
to  be  given  in  doses  of  from  one  teaspoonful  to  one  tablespoonful 
after  meals  for  one  week,  followed  for  one  week  by  the  syrup  of  the 
hypophosphites,  when  the  oil  and  malt  may  be  resumed  for  the  same 
time,  thus  alternating  indefinitely  with  the  hypophosphites.  If 
an  examination  of  the  blood  shows  that  the  patient  is  anemic, 
iron  may  be  used  in  connection  with  the  other  remedies.  The 
citrate  of  iron  and  the  extractum  ferri  pomatum  are  well  borne 
by  the  stomach  and  have  appeared  to  be  of  considerable  service 
in  some  of  my  cases.  For  children  from  five  to  ten  years  of  age, 
one  grain  of  the  citrate  of  iron  and  quinin,  or  one  grain  of  citrate 
of  iron  and  ammonia,  may  be  given  after  meals.  The  dose  of 
extractum  ferri  pomatum  at  this  age  is  one-half  grain  after  each 
meal. 


HEREDITY  AND  ENVIRONMENT 

Many  of  the  diseases,  crimes,  and  failures  of  life  are  attributed 
to  heredity,  as  are  also  vigor  of  body,  attainments,  and  successes. 
Heredity  and  environment  are  two  important  determining  factors 
in  the  Ufe  of  the  child.  Both  exert  their  influence  over  the  individual. 
I  had  been  taught  or  in  some  way  conceived  the  idea  that  the 
influence  of  heredity  was  predominant,  but  with  the  closest  asso- 
ciation with  developing  children,  coming  into  intimate  relations 
with  hundreds  of  them  and  watching  carefully  their  physical  and 
mental  development,  the  great  influence  exerted  by  environment, 
which  often  means  only  opportunity,  has  been  forced  upon  me, 
relegating  heredity  to  the  background.  That  certain  diseases,  such 
as  syphilis  and  hemophilia,  may  be  transmitted  from  parent  to 
child  is  undisputed ;  that  certain  physical  states — the  so-called  con- 
stitutional vices — may  also  be  transmitted,  is  indisputable;  but 
that  much  of  natural  physical  weakness  and  hereditary  tenden- 
cies may  be  overcome  by  the  beneficial  influence  of  environment 
is  now  universally  acknowledged.  Heredity  without  favorable  en- 
vironment counts  for  little.  Given  an  ideal  heredity  for  a  child  or 
one  of  the  lower  animals,  place  him  under  unfavorable  conditions 
of  environment  and  his  favorable  heritage  counts  for  little.  Feed- 
ing, care,  and  general  good  management  shape  his  physical  future 
much  more  than  does  inheritance.  In  proof  of  supposed  inherited 
mental  traits,  the  offspring  of  criminals  or  drunkards  are  pointed  out 
as  showing  how  they  follow  in  the  footsteps  of  their  fathers  and 
mothers.  It  must  be  admitted  that  here  the  hereditary  influence 
is  bad,  but  one  should  remember  that  their  environment  has  also 
been  very  unfavorable. 

Mental  traits  much  more  than  physical  are  apt  to  have  an  in- 
fluence on  the  future,  and  here  again  brilliant  fathers  rarely  transmit 
their  higher  mental  powers  to  their  offspring,  as  is  proved  again 
and  again  in  the  professional  and  business  world.  Many  of  the  ills 
laid  at  the  door  of  heredity  are  due  to  errors  in  early  management. 
In  the  breeding  of  animals  great  stress  is  laid  upon  pedigree,  and 
credit  is  given  accordingly.  It  should  be  remembered,  however, 
that  the  stock-raiser  appreciates  the  value  of  the  young  of  his  herds, 
and  they  invariably  get  the  care  that  is  best  calculated  to  develop 
the  perfect  animal,  which  is  exactly  what  the  majority  of  the  children 
of  the  human  family  do  not  get.  A  well-bred  animal  treated  as 
badly  from  its  birth  to  maturity  would  cut  a  sorry  figure  in  the 
animal  world. 

431 


432  HEREDITY  AND   ENVIRONMENT 


HABITS 

Children  readily  acquire  habits,  good  or  bad.  Under  the  man- 
agement of  an  intelligent  attendant,  directed  by  the  physician, 
this  natural  tendency  toward  the  repetition  of  an  act  may  be  turned 
to  the  child's  inestimable  advantage.  There  should  be  established 
in  earliest  infancy  the  habit  of  taking  the  nourishment  at  definite 
periods,  and  as  the  child  increases  in  age,  proper  habits  of  sleep 
and  rest  must  also  be  acquired.  The  child,  too,  should  be  bathed 
at  a  stated  time  and  aired  at  a  stated  time  each  day,  and,  in  general, 
in  order  to  fulfil  the  requirements  of  vigorous  animal  life,  his  life 
should  conform  to  a  routine  in  which  there  is  but  Uttle  variation. 
Our  sole  object  being  the  production  of  a  good  adult,  only  those 
habits  tending  toward  proper  growth  and  development  should  be 
encouraged.  The  habit  of  self-entertainment  is  an  important  one. 
An  infant  who  requires  to  be  constantly  in  arms  when  awake  means 
a  tired  attendant,  and  usually  a  tired  and  irritable  child. 

Bad  Habits  and  Their  Correction. — Among  the  bad  habits  early 
acquired  and  difficult  to  break,  is  that  of  thumb-sucking  or  finger- 
sucking  and  the  use  of  the  "pacifier."  The  penalty  paid  by  these 
children  for  such  indulgence  is  thickened,  boggy  lips  due  to  hyper- 
trophy of  the  orbicularis  oris  muscle  and  adjacent  structures.  Per- 
sistent sucking  also  produces  a  forward  projection  of  the  upper 
incisor  teeth  and  an  angular  deformity  of  the  upper  jaw.  The  cor- 
rection of  the  rubber-nipple  and  pacifier  habit  is  readily  accom- 
plished by  the  immediate  withdrawal  of  these  articles.  The  child 
will  experience  several  fretful  days  and  make  it  unpleasant  for  those 
about  him.  The  thumb-sucking  habit  may  be  corrected  by  having 
the  child  wear  a  mitten  or  glove  made  of  muslin  or  old  Hnen  which 
is  shirred  and  tied  at  the  wrists.  Applying  bitter  drugs  to  the  fingers 
or  thumb  is  usually  effective  in  controlling  the  habit.  The  tincture 
of  aloes  or  a  solution  of  the  bisulphate  of  quinin,  one  dram  to  two 
ounces  of  water,  is  generally  used,  the  finger  being  repeatedly  moist- 
ened with  the  solution.  Mothers  wdll  sometimes  tell  us  with  con- 
siderable amusement  that  the  application  of  the  bitter  drug  to  the 
finger  makes  no  difference  to  the  child,  who  appears  to  like  the  taste 
of  quinin  or  aloes.  The  child,  however,  soon  tires  of  the  bitter  taste, 
and  its  continued  use  will  always  stop  the  habit.  Biting  the  finger- 
nails may  likewise  be  remedied  by  the  use  of  these  bitter  solutions. 

The  most  pernicious  habit,  masturbation,  is  referred  to  on  page  433. 

It  is  surprising  in  how  many  ways  children  will  develop  habits 
of  manipulating  different  parts  of  the  body.  One  of  my  most 
troublesome  cases  was  in  a  child  one  year  old  who  came  to  me  with 
an  ear  stretched  to  twice  its  normal  size.  During  the  greater  part 
of  its  waking  hours  the  child  grasped  and  pulled  at  the  top  of  the 
left  ear. 


MASTURBATION  433 

Another  case  was  in  a  patient  who  was  brought  because  of  the 
habit  of  burrowing  the  right  thumb  into  the  right  nostril.  The 
nostril  had  become  stretched  to  at  least  three  times  its  normal 
size,  causing  a  most  peculiar  deformity. 

It  is  impossible  to  make  other  than  general  suggestions  for  the 
correction  of  bad  habits  in  children.  When  there  is  manipula- 
tion of  the  mouth,  the  sense  of  taste  can  usually  be  made  to  aid 
us.  In  other  instances  restrictions  of  a  mechanical  nature  may 
be  necessary.  In  the  ear-pulling  case,  a  tight-fitting  muslin  cap 
was  worn  constantly  and  the  right  hand  kept  pinned  to  the  clothing. 
Punishment,  rewards,  and  ridicule,  all  may  be  effectively  used  in 
the  treatment  of  these  cases.  Regarding  bad  habits  as  to  hours 
for  feeding  and  sleeping,  as  well  as  the  habit  of  carrying  a  child 
in  arms — all  may  be  corrected  by  doing  the  right  thing  at  the  right 
time  and  having  a  sufificient  amount  of  courage  to  persist  in  it.  It 
is  to  be  remembered  that,  regardless  of  its  age,  a  child  is  never 
harmed  by  rigid  discipline  properly  applied. 

MASTURBATION 

Before  the  fifth  year  a  great  many  more  cases  of  masturbation 
are  seen  among  girls  than  among  boys.  After  that  age  it  is  more 
frequent  in  boys.  The  most  common  means  of  practising  mastur- 
bation in  either  sex  in  infancy  is  by  leg-rubbing.  Contact  by  means 
of  the  edge  of  a  chair  or  the  corner  of  a  sofa  or  any  object  against 
which  pressure  may  be  exerted  is  not  infrequently  the  means 
used  in  older  girls.  Manipulation  of  the  parts,  while  only  occa- 
sionally seen  in  girls,  is  the  usual  method  in  boys  after  the  third 
year.  My  youngest  case  was  in  a  female  child  six  months  of  age 
who  was  a  "leg-rubber,"  and  who  evidently  passed  through  a  com- 
plete orgasm.  In  many  the  habit  will  be  indulged  in  several  times 
a  day. 

In  boys  the  primary  causes  of  the  practice,  other  than  that  of  a 
neurotic  habit,  are  an  elongated  foreskin,  adherent  prepuce,  and  phi- 
mosis. The  handling  of  the  parts  necessary  to  keep  the  uncircum- 
cised  clean  is  an  exciting  factor.  In  girls,  vulvitis  and  vaginitis, 
with  their  resulting  irritations,  which  are  not  relieved  by  cleansing 
and  keeping  the  parts  dry,  are  frequent  causes.  It  is  a  popular 
notion  that  thread-worms  may  be  an  exciting  factor;  but  among 
many  cases  of  masturbation  and  many  cases  of  thread-worms  I  have 
never  seen  both  in  the  same  child. 

Prophylaxis. — Masturbation  is  much  easier  to  prevent  than  cure. 
In  boys,  prevention  lies  in  having  a  clean,  free  glans,  which  in  the 
great  majority  of  male  infants  can  be  obtained  only  after  proper  sur- 
gical procedures.  The  elongated,  thickened,  uncut  portion  of  the 
foreskin  usually  seen  below  the  glans  after  a  ritual  circumcision  is 
but  Httle  better  than  a  free,  elongated  prepuce.  The  sHtting  of  the 
28 


434  HEREDITY  AND  ENVIRONMENT 

foreskin  which  is  sometimes  produced  by  the  so-called  dorsal  slit 
gives  results  very  similar  in  character  to  a  long,  redundant  foreskin. 
In  girls,  prevention  in  a  certain  degree  rests  in  keeping  the  parts 
clean  through  washing  them  once  a  day  with  great  gentleness,  and 
the  free  use  of  non-irritating  absorbent  powders.  A  powder  com- 
posed of  equal  parts  of  powdered  starch  and  oxid  of  zinc  gives  very 
satisfactory  results. 

With  the  habit  of  masturbation  once  established,  the  first  step 
is  to  eliminate  the  cause,  if  it  can  be  discovered,  and  put  the  parts 
in  a  normal  condition.  Circumcision  in  boys,  releasing  the  adhesions 
to  the  clitoris  in  girls,  with  cleanliness  and  as  Uttle  manipulation 
as  possible,  are  absolutely  essential. 

•  The  urine  should  be  examined,  and  if  found  highly  acid,  it  should 
be  corrected  by  diet  and  by  the  use  of  bicarbonate  of  soda,  from 
six  to  twelve  grains  being  given  daily,  according  to  the  age  of  the 
patient.     If  red  meat  has  formed  a  considerable  part  of  the  diet, 


Fig.  50. — Knee-crutch. 

the  quantity  should  be  reduced  and  given  not  oftener  than  three 
times  a  week. 

Having  removed  all  possible  sources  of  local  irritation,  we  are 
in  a  position  to  use  restrictive  measures,  as  it  is  through  such  treat- 
ment only  that  a  cure  will  finally  be  effected.  If  the  practice  is 
prevented  the  habit  will  soon  be  forgotten.  The  older  the  child, 
the  more  difficult  will  be  the  cure.  The  restrictive  measures  em- 
ployed depend  to  a  considerable  extent  upon  the  age,  sex,  and 
method  of  practice.  In  young  children  of  both  sexes  who  practise 
leg-rubbing,  a  large  napkin  of  some  coarse  material,  or  a  towel, 
is  placed  over  the  napkin  usually  worn,  and  applied  in  the  same 
way,  so  as  to  keep  the  legs  widely  separated.  After  the  napkin 
age  a  large  towel  may  also  be  used,  if  necessary,  for  the  same  pur- 
pose, or  the  knee-crutch  (Fig.  50)  may  be  employed.  Some  children 
will  indulge  only  when  in  a  certain  chair  or  in  a  certain  posi- 
tion. 


MASTURBATION 


435 


Illustrative  Cases. — A  very  troublesome  case  in  a  girl  seventeen 
months  old  was  treated  without  success  for  several  weeks,  when  I 
discovered  that  the  child  practised  the  act  only  when  in  her  high 
chair,  as  by  leaning  forward  and  grasping  the  projecting  arms  she 
managed  to  bring  the  necessary  pressure  to  bear  upon  the  genitals. 
The  use  of  the  chair  being  discontinued,  there  was  no  further  trouble. 

Another  child,  a  girl  six  years  of  age,  was  an  inveterate  mastur- 
bator.  She  had  been  treated  by  several  physicians.  The  act  was 
repeated  daily,  sometimes  two  or  three  times  a  day,  usuallv  by  con- 
tact, such  as  by  pressure  against  the  corner  of  a  table,  sofa,  or  chair. 


?RACE  Used  to  Prevent  Mantai.  Masturbation. 


When  in  bed,  she  indulged  in  the  practice  by  manipulation.  She  had 
become  pale,  thin,  and  hysterical,  and  being  a  member  of  a  promi- 
nent family,  great  concern  was  felt  for  her.  It  seemed  that  here 
was  a  case  where  eternal  vigilance  was  the  price  of  safety.  The 
external  genitals  were  congested  and  swollen  as  a  result  of  the 
direct  irritation,  otherwise  they  were  normal.  The  gravity  of  the 
condition  was  apparent,  and  the  parents  readily  agreed  to  my  sug- 
gestion that  the  child  should  never  be  left  alone.  The  mother 
and  the  nursery  maid  took  turns  in  being  with  the  child  in  the 
daytime.     A  trusty  middle-aged  woman  was  selected  for  the  night 


436  HEREDITY  AND  ENVIRONMENT 

watch.  I  directed  that  no  reference  be  made  to  the  habit,  but  that 
the  child  should  be  severely  punished  if  the  practice  was  attempted. 
This,  however,  was  not  needed.  This  child,  as  is  the  case  with  all 
older  children,  masturbated  in  secret,  and  as  she  was  never  left 
alone  the  practice  was  stopped.  She  was  given  suitable  food, 
teaching  by  a  visiting  governess  was  begun,  and  hard  play  was 
soon  advised,  as  her  physical  improvement  was  rapid.  As  there 
was  no  further  tendency  to  masturbate,  the  night  watch  was  reUeved 
after  six  months.  The  child  was  kept  under  the  closest  observation, 
however,  for  a  much  longer  time.  Cooperation  to  such  a  degree 
as  in  this  family  can,  however,  rarely  be  secured. 

Older  children  who  practise  manipulation  of  the  parts  can  usually 
be  watched  during  the  daytime,  but  the  habit  is  apt  to  be  indulged 
in  on  going  to  bed,  after  the  lights  are  out,  and  in  the  early  morning, 
particularly  when  it  is  prevented  during  the  day.  In  such  instances, 
I  have  been  obUged  to  advise  mechanical  restraint.  An  inexpensive 
and  effective  means  is  to  use  a  piece  of  tape,  which  is  tied  in  the 
center  around  the  child's  neck  in  a  flat  knot,  leaving  the  two  ends 
long  enough  to  be  securely  tied  around  the  child's  wrists,  so  as  to 
allow  a  free  movement  of  the  hands  above  the  umbilicus.  The 
child  can  use  the  handkerchief,  and  adjust  the  bed-clothing,  but 
cannot  touch  the  genitals.  If  the  patient  is  a  girl  and  a  mastur- 
bator  by  contact  with  any  object,  or  a  leg-rubber,  a  large  bath-towel, 
if  worn  like  an  infant's  napkin,  will  aid  materially  in  discouraging 
the  practice.  A  brace  (Fig.  51),  constructed  of  steel,  with  a  hinge- 
joint  to  allow  the  arm  to  be  extended  to  an  angle  of  about  45  de- 
grees, has  been  used  with  success  in  a  few  cases.  This  brace  is  worn 
only  at  night. 


CONSTITUTIONAL  DISORDERS 

ICTERUS— OBSTRUCTIVE  JAUNDICE 

Jaundice  of  this  type  in  children  is  usually  associated  with 
duodenitis  and  is  caused  by  a  swelHng  of  the  mucous  membrane 
of  the  common  bile-duct  at  its  terminal  opening  into  the  intestine, 
and  is  due  probably  to  the  same  form  of  infection  that  caused  the 
duodenitis.  I  have  seen  but  one  case  in  which  the  jaundice  was 
due  to  cholelithiasis — that  of  a  girl  six  years  of  age.  The  patient 
had  distinct  attacks  of  biliary  colic  with  passage  of  gall-stones  and 
followed  by  intense  jaundice.  She  was  operated  upon  later  and 
many  stones  removed  from  the  gall-bladder. 

The  onset  of  my  cases  has  been  almost  invariably  without  high 
temperature,  or  the  evidence  of  severe  gastric  disturbance.  Usually 
the  first  sign  that  something  is  wrong  with  the  child  is  a  loss  of 
appetite,  a  degree  or  two  of  temperature,  a  coated  tongue,  and 
listlessness.  The  yellow  discoloration  of  the  conjunctivae  and  the 
skin  soon  appears,  which  with  the  high-colored  urine  and  slightly 
colored  or  grayish  stools  makes  the  case  complete. 

Treatment. — Diet. — The  reason  why  gastric  disorders  are  consid- 
ered so  prominent  a  symptom  by  many  writers  is  possibly  because 
of  the  gastric  disturbance  produced  by  their  treatment.  We  are 
advised  to  place  the  patient  on  a  milk  diet  and  give  calomel.  I 
know  of  no  treatment  better  calculated  to  produce  vomiting  and  in- 
crease both  the  intestinal  infection  and  the  jaundice.  The  treat- 
ment which  I  have  found  most  satisfactory  is  the  use  of  very  little 
food  for  twenty-four  hours.  Water  is  given  as  a  drink  and  chicken 
or  mutton  broth  well  salted  may  be  given  with  toast  later  if  the 
child  asks  for  food.  He  should  not  be  urged  to  eat.  The  following 
day,  broths,  gruels,  and  orange-juice,  with  stewed  fruits  or  lemonade, 
are  given  if  the  child  wants  them. 

Drugs. — The  only  medication  used  consists  of  rhubarb  and  soda. 
To  a  child  five  years  of  age  I  give  foul  grains  of  pulverized  rhubarb 
and  eight  grains  of  bicarbonate  of  soda  from  two  to  three  times  daily, 
giving  at  the  same  time  considerable  water.  For  a  day  or  two  suffi- 
cient should  be  given  to  produce  a  free  laxative  effect,  but  not  neces- 
sarily to  purge  the  patient.  Usually  on  the  third  day  I  begin  with 
tincture  of  nux  vomica  and  dilute  hydrochloric  acid — from  two  to 
four  drops  of  each,  well  diluted.  With  the  return  of  the  stools  to 
the  normal  the  usual  diet  may  be  resumed,  milk  not  being  given 
for  a  week  afterward.     Rhubarb  and  soda  are  best  given  as  follows : 

437 


438  CONSTITUTIONAL   DISORDERS 

I^.     Pulveris  rhei gr.  xlviij 

Sodii  bicarbonatis gr.  xcvj 

Syrupi  rhei  aromaticae §j 

Aquae q.  s.  ad  ^ij 

M.     Sig. — Shake  well.     Give  one  teaspoonful  two  or  three  times 
daily  after  meals. 

OBESITY 

Exceedingly  fat  children  will  usually  be  found  to  be  large  eaters 
and  of  inactive  habits.  It  is  rarely  a  serious  condition  and  ordi- 
narily requires  little  more  than  certain  restrictions  in  diet  and 
regularity  in  exercise.  Generally  this  is  not  difficult  to  obtain,  as 
the  patient  is  usually  very  anxious  to  reduce  the  weight  because 
of  the  attention  he  attracts  and  the  remarks  the  condition  occasions 
in  pubHc  places  and  among  school-fellows. 

Treatment. — Diet. — In  such  cases  I  direct  that  all  fatty  foods, 
including  butter  and  milk,  be  excluded  from  the  diet.  Skimmed 
milk  may  be  given  in  moderation — not  over  one  pint  daily.  It  may 
be  used  on  the  cereal,  and  eight  ounces  may  be  given  as  a  drink  if 
the  child  is  fond  of  it.  The  use  of  sugar,  including  candy  and  sweets 
of  all  kinds,  is  forbidden.  Saccharin  dissolved  in  the  milk  is  used  on 
the  cereal  and  in  making  stewed  fruits  and  plain  puddings  palatable. 

Exercise. — During  the  warmer  months,  golf,  swimming,  tennis, 
horseback  exercise,  and  the  bicycle  are  advised,  a  definite  time, 
in  hours,  being  prescribed  each  day  for  some  active  physical  exercise. 
During  the  cold  months,  roller-skating,  ice-skating,  horseback-riding, 
out  of  doors  when  possible  and  indoors  on  inclement  days,  when  the 
means  are  at  hand,  together  with  long  walks,  are  a  part  of  the  daily 
life.  A  schedule  is  prescribed  and  written  out  for  each  day,  depend- 
ing somewhat  upon  the  station  in  life  of  the  patient,  not  only  as 
regards  food  but  also  as  regards  outdoor  exercise.  In  this  way,  by 
estabhshing  a  system  of  living  covering  the  entire  day,  there  will 
result,  if  the  family  cooperate,  a  reduction  of  the  obesity  with  a 
marked  improvement  in  the  patient's  general  condition. 

Drugs. — The  use  of  thyroid  extract  and  other  drugs  for  the  reduc- 
tion of  weight  in  children  is  not  to  be  advised. 

During  the  treatment  the  child  should  be  weighed  regularly,  as 
too  pronounced  results  are  not  desired. 

THE  ANEMIAS  OF  INFANCY  AND  CHILDHOOD 
A  description  of  the  treatment  of  the  various  forms  of  anemia 
as  seen  in  the  young,  would  be  a  repetition  to  a  considerable  extent 
of  the  management  of  malnutrition.  Every  child  with  anemia 
suffers  to  a  certain  degree  from  malnutrition  also.  The  etiology 
of  practically  all  the  severer  blood  diseases  in  children,  such  as  chlo- 
rosis, leukemia,  the  pseudoleukemic  anemia  of  Van  Jaksch,  and  perni- 
cious anemia,  is  but  little  understood. 

Treatment. — Cases  of  secondary  anemia  must  be  treated  along 


THE    ANEMIAS    OF    INFANCY    AND    CHILDHOOD  439 

symptomatic  lines.  Disordered  intestinal  digestion  with  its  result- 
ing toxemias  and  systemic  poisoning,  which  are  also  little  under- 
stood, doubtless  plays  a  major  role  in  the  blood  diseases.  The 
management  of  anemia  in  the  young  resolves  itself  into  a  cor- 
rection of  existing  digestive  errors.  The  bottle-fed  baby  suflfering 
from  a  grave  form  of  anemia  is  given  a  better  chance  for  recovery 
if  he  is  placed  on  the  breast.  A  wet-nurse  should  alwavs  be  se- 
cured, if  possible.  When  this  is  not  possible  the  child's  food  should  so 
be  arranged  as  best  to  fit  his  digestive  capacity,  remembering  that 
as  high  a  proteid  as  is  compatible  with  digestion  should  be  given. 
These  children  also  require  all  the  advantages  furnished  by  bathing 
and  fresh  air.  An  indoor  airing  (page  37)  for  hours  at  a  time 
should  always  be  given  these  children  when  they  cannot  be  sent 
out  of  doors.  The  sleeping  apartment  should  always  communicate 
with  the  open  air.  If  the  patient  is  of  school-age,  the  time  when 
we  see  most  of  the  secondary  anemias,  he  should  be  allowed  to  attend 
only  the  morning  session  and  be  forced  to  rest  for  an  hour  or  two 
after  the  midday  meal.  While  exercise  and  play  are  necessary, 
they  should  not  be  allowed  to  the  point  of  fatigue.  More  clothing 
will  be  required,  both  in  winter  and  summer,  than  is  needed  for  well 
children  of  the  same  age  in  the  same  climate.  Among  my  dispensary 
patients  I  see  a  goodly  number  of  these  cases.  I  insist  that  the  child 
shall  occupy  the  sleeping-room  alone  and  direct  that  the  living- 
room  or  "parlor  room,"  as  it  is  sometimes  called  by  these  people, 
be  used  as  the  sleeping-room  of  the  patient.  If  the  parents  are  suffi- 
ciently well-to-do  to  send  the  child  to  the  country,  this  is  advised. 

As  with  all  forms  of  malnutrition  in  children,  the  diet,  when 
there  is  an  associated  anemia,  is  most  important.  A  high-proteid 
diet  should  be  given;  red  meat  at  least  once  a  day,  poultry,  fish, 
eggs,  milk,  and  butter;  oatmeal,  cracked  wheat  (each  cooked  three 
hours),  together  with  the  legumes  and  potatoes,  should  form  the  basis 
of  the  dietary.  Better  results,  I  find,  are  obtained  by  selecting  foods 
that  are  rich  in  iron  than  when  inorganic  iron  is  given  as  medicine. 

The  following  table  of  Bunge  may  be  of  assistance  in  the  selection 
of  food  for  anemic  children.  It  gives  the  number  of  milHgrams  of 
iron  in  the  dried  substances: 


Corn 

Wheat  flour 

1.0 

-2.0 
1.6 
2.3 

-3.1 
3.7 
3.9 
4.3 
4.5 
4.9 
4.9 
5.5 
5.7 
6.4 

Peas 

Black  Cherry 

....    6.; 

2-6.6 
7  2 

Bovine  milk 

'.'.'.'.'.2.3 

8  3 

Human  milk 

Carrots 

Strawberries 

Lentils 

Red  Cherries. 

8.6 

Raspberries 

9  5 

Hazelnuts 

10  0 

Barley 

Almond 

Rye 

Wheat 

Apples 

Beef 

Asparagus 

Yolk  of  egg. . 

10  0- 

13.0 

17.0 

20.0 

-24  0 

Buckwheat 

Potato 

Spinach 

....33.0- 

-39.0 

44©  CONSTITUTIONAL    DISORDERS 

It  will  be  seen  from  the  foregoing  that  the  diet  of  many  "run- 
about "  children,  viz.,  milk  and  the  products  of  wheat  flour,  such 
as  white  bread,  crackers,  and  cake,  are  substances  comparatively 
poor  in  iron,  and  this  doubtless  helps  to  explain  many  of  the  anemias 
found  at  this  age  among  the  poorer  classes. 

Iron. — In  a  great  majority  of  instances  in  which  iron  is  given 
to  children  it  is  used  indiscriminately,  in  too  large  doses,  and  usu- 
ally without  benefit.  It  is  doubtless  prescribed,  on  general  princi- 
ples, more  frequently  than  any  other  drug.  I  am  yet  to  be  convinced 
that  it  possesses  any  great  value  in  the  blood  disorders  in  children 
other  than  chlorosis.  Of  this  I  am  certain :  when  it  is  given  without 
suitable  attention  to  nutrition,  digestion,  bowel  function,  and  general 
hygiene,  iron  is  of  no  benefit,  and  is  more  frequently  harmful,  because 
it  is  very  apt  to  increase  the  defective  intestinal  elimination,  a  con- 
dition usually  present  in  anemia.  The  blood  of  the  average  child 
three  years  of  age  contains  at  the  most  only  about  six  grains  of  iron. 
The  advantage  of  prescribing  three  or  four  grains  daily  for  a  child 
of  this  age  should  hardly  be  considered.  My  results  in  secondary 
anemia  have  usually  been  satisfactory  without  iron  when  the  pre- 
scribed diet  and  hygienic  regulations  were  carried  out.  Iron  is 
useful,  however,  in  selected  cases  of  anemia  and  of  considerable 
service  in  chlorosis. 

In  the  selection  of  preparations  of  iron,  those  which  are  least 
irritating  to  the  stomach,  and  the  least  constipating,  should  be 
chosen.  With  this  in  view,  the  citrates  should  be  selected  if  the 
drug  is  to  be  given  in  liquid  form.  They  are  soluble  in  water 
and  produce  less  digestive  disturbance  than  do  the  other  forms. 
The  citrate  of  iron  and  ammonia  and  the  citrate  of  iron  and  quinin, 
particularly  the  latter,  have  been  found  satisfactory.  The  dosage 
for  a  child  two  years  of  age  or  older  is  one  grain,  which  is  best  given 
in  sherry  wine  after  meals.  Where  a  patient  can  swallow  a  pill  or 
a  capsule,  the  extractum  ferri  pomatum  in  doses  of  from  j  to  ^  grain, 
three  times  daily,  alone  or  combined  with  nux  A^omica  or  quinin, 
will  benefit  the  patient  as  much  as  iron  is  capable  of.  If  the  anemia 
and  malnutrition  are  due  to  a  remote  congenital  syphilitic  infection 
(page  393),  bichlorid  of  mercury  in  small  doses — ^-q  to  -^j^  grain, 
three  times  daily — is  often  productive  of  marvelous  results.  To 
my  young  patients  suffering  from  malnutrition,  particularly  those 
in  whom  I  am  not  certain  of  the  family  history,  I  often  give  mercury 
in  order  to  make  a  diagnosis  more  certain. 

Chlorosis  occurs  in  young  girls  about  the  time  of  puberty  or 
later.  It  is  a  disease  in  which  drugs  are  given  with  most  satis- 
factory results.  Here  iron  and  arsenic  do  good  service,  although 
I  have  seen  cases  which  showed  no  improvement  under  medication 
make  complete  recoveries  after  a  change  of  food  and  place  of  residence 
from  the  city  to  the  country.     Among  the  various  lines  of  medica- 


RACHITIS  441 

tion    I    have   found    the   following   combination  the   most  service- 
able: 

I^.     Tincturae  nucis  vomicae gtt.  cxx 

Extracti  cascarae  sagrad^e gr.  x 

Extract!  ferri  pomati gf-  xv 

Liquoris  potassii  arsenitis gtt.  cxx 

QuininEe  bisulphatis 5j 

M.  div.  et  ft.  capsulae  No.  xxx. 

Sig. — One  after  each  meal. 

This  is  given  for  ten  days,  and  repeated  after  five  days'  inter- 
mission. Interrupted  medication  is  thus  continued  until  recovery 
follows  or  until  it  is  demonstrated  that  other  drugs  must  be  used. 
A  patient  with  chlorosis  should  have  all  the  advantages  of  diet  and 
change  of  scene  that  the  circumstances  of  the  family  will  permit. 

RACHITIS 

Rachitis  is  a  disease  of  nutrition,  and  is  peculiar  in  that  a  greater 
part  of  the  structures  which  make  up  the  infant  organism  are  in- 
volved in  the  rachitic  processes.  The  bones  show  the  character- 
istic deformities,  the  most  common  of  which  are  the  enlarged 
epiphyses,  the  square  head,  the  open  fontanel,  the  beaded  ribs,  and 
the  lateral  chest  curves.  The  muscles  are  undeveloped  and  flabby, 
the  mucous  membranes  are  prone  to  catarrhal  inflammations,  and 
the  nervous  system  shows  a  lack  of  development;  rachitic  children 
being  particularly  susceptible  to  disorders,  such  as  laryngismus 
stridulus  and  infantile  convulsions.  Rachitic  children  are  inva- 
riably anemic.  Dentition  is  delayed,  and  when  the  teeth  appear 
they  are  apt  to  come  in  groups  of  four  or  more  at  one  time  and 
occasion  no  little  disturbance.  Repeatedly  it  happens  that  the 
first  teeth  are  not  cut  until  after  the  fifteenth  month.  Rachitic 
children  are  late  in  walking,  suffer  from  constipation,  and  are  usually 
below  the  average  weight  and  size;  in  short,  a  child  with  rachitis 
is  unique  in  the  sense  that  he  is  constitutionally  below  the  normal 
in  every  respect  as  regards  growth,  development,  and  resistance 
to  untoward  influences.  The  rachitic  child  is  an  easy  mark  for 
any  disease  which  may  be  prevalent,  and  while  rachitis  itself  is  not 
a  fatal  disease,  it  contributes  no  small  part  to  infant  mortality 
because  of  the  low  vitality  which  is  characteristic  of  the  condition. 
Bronchopneumonia,  pertussis,  and  the  gastro-enteric  affections  are 
all  very  dangerous  in  rachitic  infants.  Italians  and  the  colored 
race  are  particularly  stisceptible  to  the  disease.  While  well-marked 
rachitis  is  rare  before  the  sixth  month,  infants  two  or  three  months 
of  age  show  the  beginning  characteristic  changes  in  the  muscles  and 
bones. 

Much  has  been  written  regarding  the  etiology  of  the  disease  in 
its  relation  to  climate  and  unhygienic  surroundings,  and  while 
such  surroundings  may  contribute  to  the  result,  I  have  yet  to  be 


442  CONSTITUTIONAL    DISORDERS 

convinced  that  as  etiologic  factors  they  are  very  important.  It 
is  true  that  we  usually  find  rachitic  children  with  unhygienic  sur- 
roundings, but  thousands  of  others  who  live  under  the  same  condi- 
tions do  not  have  rachitis.  A  child  fed  on  normal  breast-milk 
will  endure  much  that  is  not  hygienic  and  still  not  develop 
rachitis. 

In  the  treatment  of  several  thousand  rachitic  children,  one  fact 
has  impressed  me  most  strongly:  Given  a  child  suffering  from 
rachitis,  we  have  a  child  suffering  from  nutritional  errors  as  a  result 
of  improper  feeding,  or  an  inability  to  assimilate  a  suitable  food; 
and  I  have  yet  to  see  a  case  which  did  not  improve  when  suitable 
nourishment  could  be  given,  and  assimilated,  regardless  of  the  age 
of  the  patient.  In  children  under  one  year  of  age  the  feeding  of 
the  proprietary  foods  or  condensed  milk  is  the  most  frequent  cause 
of  the  disease.  The  next  most  frequent  cause  is  the  feeding  of  a 
too  strong  cow's-milk  mixture,  which  produces  indigestion  and 
faulty  assimilation.  Breast-fed  babies  among  the  Italians  and 
negroes  occasionally  have  rachitis,  and  an  examination  of  the  breast- 
milk  will  invariably  show  a  diminution  of  one  or  more  of  the  nutri- 
tional elements — usually  the  proteid. 

A  nursing  woman  in  the  New  York  Infant  Asylum  had  such 
a  free  flow  of  milk  that  a  foster-child  was  given  her  to  nurse.  The 
children  failed  to  thrive;  each  made  a  gain  of  but  two  or  three 
ounces  weekly;  both  developed  rachitis,  one  in  a  marked  degree. 
Repeated  examinations  of  the  breast-milk  showed  it  to  contain 
1.5  percent  fat,  4  percent  sugar,  and  0.5  percent  proteid. 

After  the  first  year  fewer  cases  develop,  but  a  late  rachitis  is 
bv  no  means  uncommon.  In  my  own  cases  the  development  of 
the  disease  at  this  age  and  after,  as  in  the  very  young,  has  been 
distinctly  traceable  to  faulty  feeding  and  faulty  digestion.  Not 
a  few  cases  between  the  second  and  third  years  were  considered 
due  to  prolonged  nursing.  I  have  known  just  two  mothers  who 
could  nurse  their  children,  and  substantially  nourish  them,  by 
the  breast  later  than  the  twelfth  month.  Usually  when  the  breast 
furnishes  the  only  means  of  nourishment  after  the  first  year  of  life, 
a  beginning  rachitis  will  soon  be  noticed.  The  feeding  after  the  first 
year  of  an  exclusive  diet  of  milk  or  of  indigestible  starches  is  not  in- 
frequentlv  a  cause  of  rachitis.  Among  the  poorer  classes  children 
during  the  second  and  third  years  are  almost  always  badly  fed. 
The  diet  usually  consists  of  poor  milk  and  poorly  cooked  starches. 
Children  thus  fed  furnish  no  small  part  of  our  rachitic  patients. 

Treatment. — It  will  readily  be  seen  from  the  foregoing  that  the 
treatment  of  rachitis  resolves  itself  into  the  adjustment  of  the  diet 
to  the  needs  of  the  patient.  As  growth  and  normal  development 
cannot  take  place  without  proteid,  and  as  the  history  of  our  cases 
has  shown  that  this  is  the  element  which  is  most  frequently  lacking 


RACHITIS  443 

in  the  diet  of  rachitic  children,  the  feeding  of  the  proper  amount  of 
proteid  should  be  our  first  consideration. 

The  artificial  foods  and  condensed  milk  are  deficient  in  that  in 
them  both  the  fat  and  the  proteid  are  low;  therefore  these  foods 
should  be  discontinued  and  a  properly  adapted  cow's  milk  substi- 
tuted. This  appUes  to  children  under  one  year  of  age.  In  a  great 
many  cases  this  is  the  only  treatment  required. 

Diet. — -For  those  over  one  year  of  age,  not  only  should  the  arti- 
ficial food  be  discontinued  and  cow's  milk  given,  but  the  cow's  milk 
should  be  supplemented  by  a  diet  rich  in  nitrogen.  I  order  a  diet 
composed  largely  of  milk,  scraped  beef,  soft-boiled  egg,  oatmeal,  and 
wheat  gruel.  After  the  second  year  purees  of  beans  and  peas  are 
added  to  the  dietary  because  of  the  large  percentage  of  proteid 
which  they  contain.  It  is  impossible  to  prescribe  a  more  definite 
dietary.  The  physician  must  remember  that  a  diet  as  highly  ni- 
trogenous as  the  child  can  assimilate  is  to  be  given.  Unfortu- 
nately, many  rachitic  children  cannot  take  cow's  milk  in  quantities 
sufficient  to  make  it  of  real  nutritive  value.  This  is  often  the  result 
of  an  inability  to  digest  the  fat,  the  milk  being  taken  without  incon- 
venience when  a  large  proportion  of  the  fat  is  removed.  Skimmed 
milk  contains  at  least  3  percent  of  the  chief  nutritional  element,  the 
proteid,  and  makes  a  valuable  addition  to  the  diet.  If  a  dilution  of 
the  milk  is  necessary,  oatmeal  gruel  should  be  used. 

Many  children  who  cannot  take  a  full  milk  diet  will  take  an 
ounce  or  two  of  butter  daily  without  inconvenience.  In  older 
children  I  advise  the  free  use  of  butter,  one  or  two  ounces  daily. 
It  is  advisable  to  give  rachitic  children  a  moderate  amount  of  fat, 
as  it  aids  in  the  production  of  heat  and  thus  saves  the  tissues.  In 
children  under  one  year  of  age  cod-liver  oil  is  often  a  valuable  ad- 
dition to  the  dietary.  In  prescribing  cod-liver  oil  I  prefer  to  use 
the  plain  oil.  In  spite  of  the  disgust  adults  have  for  cod-liver  oil, 
children  usually  take  it  readily.  The  younger  the  child,  the  better 
the  oil  will  be  taken.  For  delicate  children  six  months  of  age, 
from  ten  to  thirty  drops  may  be  given  three  times  daily  after  meals. 
From  the  sixth  to  the  eighteenth  month,  from  twenty  drops  to 
a  dram  may  be  given  three  times  daily  after  feedings.  After  the 
eighteenth  month  from  one  to  three  drams  may  be  given  three 
times  daily  after  meals. 

Hygiene. — Brine  baths  and  oil  inunctions  aid  materially  in  im- 
proving the  child's  condition  as  a  whole,  and  are  of  great  value.  The 
brine  bath  (page  31),  which  is  given  at  bedtime,  is  followed  by  an 
inunction  of  goose  grease,  unsalted  lard,  or  cacao-butter.  The  goose 
oil  or  the  lard  is  preferred.  At  least  two  teaspoonfuls  should  be 
rubbed  into  the  skin.  The  benefit  derived  from  the  inunctions 
is  largely  due  to  the  massage.  The  rubbing  should  be  continued 
for  at  least  ten  minutes;  the  muscles  of  the  back  and  legs  should 


444  CONSTITUTIONAL   DISORDERS 

receive  special  attention.  In  a  few  children  the  animal  fats  act 
as  irritants  to  the  skin  and  produce  a  fine  papular  eruption. 

The  rachitic  child  should  have  plenty  of  fresh  air,  by  means 
either  of  a  fire-place  or  an  open  window.  On  stormy  and  very  cold 
days  he  should  be  given  an  indoor  airing  (page  37),  being  placed 
in  his  carriage  or  cart  and  wheeled  about  the  room,  and,  to  avoid 
drafts,  the  window  or  windows  on  only  one  side  of  the  room  should 
be  opened. 

Rachitic  children  are  very  susceptible  to  head  colds  and  bron- 
chitis; therefore  every  means  must  be  employed  to  prevent  ex- 
posure. As  creeping  and  playing  on  the  floor  are  the  most  frequent 
ways  for  a  child's  taking  cold,  the  exercise  pen  (page  37)  is  par- 
ticularly useful  in  these  cases. 

Drugs. — Drugs  in  my  experience  are  of  value  only  as  they  in- 
crease the  appetite  and  the  capacity  for  properly  selected  foods. 
The  administration  of  phosphorus  is  without  avail  if  the  deficient  diet 
is  continued.  Specific  medication  without  proper  food  and  a  fair 
digestive  capacity  is  valueless.  With  proper  food  and  a  fair  digestive 
capacity,  medication  is  superfluous,  and  a  child  rapidly  recovers 
without  it. 

Phosphorus  I  have  used  extensively  and  have  yet  to  see  a  single 
case  in  which  the  beneficial  action  of  the  drug  could  be  proved. 
In  giving  phosphorus,  the  oleum  phosphoratum  is  the  easiest  and 
most  convenient  method  of  using  it.  One  drop  of  the  preparation 
represents  y^'o  grain  of  phosphorus.  For  children  under  one  year 
of  age,  one  drop  may  be  given  three  times  daily.  For  those  between 
the  first  and  second  year,  one  and  one-half  to  two  drops  may  be 
given  three  times  daily  after  meals. 

Deformities. — The  deformities  of  the  osseous  system,  particularly 
of  the  spine  and  the  long  bones,  may  be  prevented — the  first,  by 
keeping  the  child  on  his  back  a  greater  part  of  the  time,  and  if  the 
deformity  is  well  marked,  by  teaching  him  to  sleep  resting  on  his 
stomach.  When  kyphosis  is  present  the  child  should  be  allowed  to 
remain  in  the  upright  position  but  a  few  moments  at  a  time. 

Deformities  of  the  femur,  tibia,  and  fibula  occur  long  before 
the  child  attempts  to  stand,  but  too  early  use  of  the  legs,  while  not 
necessarily  a  cause  of  deformity,  may  greatly  aggravate  the  existing 
conditions.  For  this  reason  rachitic  children  should  not  be  encour- 
aged to  walk  or  stand  until  they  have  been  under  treatment  for 
three  or  four  months. 

Operative  measures  for  the  correction  of  bow-legs  are  better 
postponed  until  after  the  third  year.  If  done  at  an  earlier  period 
the  deformity  is  apt  to  return,  and  the  late  deformity  may  be  greater 
than  the  original  one. 

In  my  experience,  the  use  of  braces  to  correct  the  deformity  of 
the  legs  has  been  of  but  little  assistance,  nor  has  any  patient  of 


SCORBUTUS.       SPORADIC    CRETINISM  445 

mine  been  benefited  particularly  when  so  treated  by  the  ortho- 
pedic surgeon.  The  use  of  braces  and  jackets  of  plaster-of- Paris  in 
kyphosis  is  usually  unnecessary.  Rest,  massage,  and  exercises  di- 
rected to  restore  power  to  the  weakened  muscles  have  answered 
well  in  my  cases. 

SCORBUTUS— SCURVY 

Inasmuch  as  scurvy  is  a  disease  caused  by  improper  feeding, 
the  management  is  largely  dietetic.  Sterilized  milk  and  the  pro- 
prietary meal  foods  are  responsible  for  a  great  majority  of  the  cases. 

Treatment. — Dietetic. — The  first  step  in  the  treatment  is  to  supply 
fresh  milk  for  the  child,  diluted,  if  necessary,  to  meet  its  digestive 
capacity.  I  have  seen  cases  in  which  the  diagnosis  was  made  early 
completely  recover  under  a  change  from  sterilized  milk  to  raw  milk, 
without  the  aid  of  any  other  measure.  Inasmuch  as  the  disease  is  a 
most  painful  one,  every  means  possible  should  be  employed  toward 
furnishing  early  relief.  Orange-juice  is  a  specific  for  the  disease.  The 
child  takes  it  greedily.  One  teaspoonful  may  be  given  at  two-hour  in- 
tervals, one  ounce  being  given  ordinarily  in  twenty-four  hours.  Un- 
less the  case  is  an  advanced  one,  with  extensive  subperiosteal  hem- 
orrhages and  separation  of  the  epiphyses,  relief  will  be  noticed  in 
twenty-four  hours  and  an  entire  cessation  of  symptoms  in  from 
five  to  seven  days.  I  have  seen  a  few  cases  entirely  relieved  at 
the  end  of  seventy-two  hours  of  treatment.  These  were  in  infants, 
in  whom  the  diagnosis  was  made  very  early — the  only  symptom 
being  the  evidence  of  pain  during  manipulation  of  the  limbs  in 
bathing  or  while  changing  the  napkin,  this  is  usually  the  first  sign 
of  the  trouble. 

Illustrative  Cases. — A  case  of  long  duration  under  treatment  was 
in  a  boy  eighteen  months  of  age,  who  had  been  on  almost  an  ex- 
clusive diet  of  a  malted  proprietary  food  from  birth.  The  illness 
had  existed  for  two  months  with  extensive  subperiosteal  hemor- 
rhages and  required  three  months  of  treatment  before  it  could  be 
considered  well.  In  a  comparatively  recent  case  in  my  service  at 
the  Babies'  Hospital,  in  which  there  was  separation  of  the  epiph3^ses 
of  the  humerus  at  the  shoulder  and  of  both  femurs  at  the  hip,  three 
weeks  were  required  to  effect  a  cure. 

The  management  of  more  severe  cases  is  the  same  as  of  those 
of  milder  type.  Fresh  food  with  orange -juice  or  beef -juice  must 
be  freely  given.  The  patients  should  be  handled  very  gently  and 
only  when  necessary,  as  the  pain  on  manipulation  of  the  involved 
parts  is  most  excruciating. 

SPORADIC  CRETINISM— INFANTILE  MYXEDEMA 
Sporadic  cretinism  is  due  to  an  absence  of,  or  to  a  derangement 
of  function  of  the  thyroid  gland.     In  cretinism  there  is  an  arrest 
of  mental  and  physical  development,  the  latter  being  of  a  character- 


446  CONSTITUTIONAL    DISORDERS 

istic  type  with  retarded  growth  and  developmental  anomalies  not 
seen  in  any  other  condition.  Without  treatment  the  cases  which 
live  through  infancy  become  dwarfs  and  idiots. 

The  Thyroid  Treatment. — The  specific  treatment  is  the  thyroid 
treatment.  The  most  pronounced  beneficial  results  of  this  treat- 
ment are  noticed  when  it  is  brought  into  use  early  in  life.  The 
diagnosis  of  cretinism  is  rarely  made  before  the  fifth  or  sixth  month, 
oftentimes  much  later,  for  the  reason  that  the  case  does  not  happen 
to  come  under  the  observation  of  those  competent  to  diagnose  it. 

Illustrative  Cases. — In  two  of  my  cases  the  patients  were  first 
seen  by  me,  one  at  the  fifth,  the  other  at  the  seventh  month.  Other 
cases  have  been  treated  in  institution  and  in  private  work;  the 
two  referred  to,  however,  were  seen  earlier  and  almost  daily  for 
months,  consequently  there  was  an  excellent  opportunity  for  observ- 
ing the  effects  of  the  thyroid  administration.  A  fairly  complete 
history  of  one  of  the  cases  is  as  follows:  The  desiccated  thyroid 
extract  of  Parke,  Davis  &  Co.  was  used.  At  first  it  was  given  in 
one -half-grain  doses  twice  daily.  The  beneficial  effects  were  noticed 
in  three  days.  The  first  change  for  the  better  was  observed  by 
the  mother,  who  stated  that  the  child  seemed  warmer  and  that  less 
bed-clothing  was  necessary.  The  next  positive  change  occurred, 
according  to  my  records,  on  the  fifth  day  of  treatment.  The  child's 
general  condition  was  very  much  improved.  Her  extremities  were 
warmer,  her  color  was  better,  and  she  commenced  to  move  her 
arms;  but  what  particularly  impressed  the  mother  was  that  less 
bed-clothing  v/as  needed  to  keep  the  child  warm.  At  about  the 
seventh  day  of  treatment  the  patient  cried  vigorously  when  dis- 
turbed in  changing  the  napkin,  something  which  she  had  never 
done  before.  She  had  previously  been  stupid  and  apathetic. 
The  next  and  rapidly  following  changes  for  the  better,  were  that 
the  patient  noticed  and  appeared  interested  in  her  mother  and 
followed  her  with  her  eyes  about  the  room,  and  while  previously 
she  had  rarely  used  her  legs  or  arms  except  when  disturbed,  she 
now  began  to  move  them  about  voluntarily ;  as  the  mother  expressed 
it:  "The  child  had  acted  as  though  she  were  under  the  influence 
of  some  powerful  depressant  drug  whose  effects  were  gradually 
wearing  off."  When  the  child  was  five  and  one -half  months  old, 
after  she  had  been  under  treatment  for  sixteen  days,  receiving 
one-half  grain  of  thyroid  twice  daily,  she  smiled  for  the  first  time. 
She  cut  the  first  tooth  at  the  ninth  month  and  walked  alone  at  the 
fourteenth  month.  She  is  now,  at  two  years  of  age,  taking  three 
grains  daily,  and  is  apparently  normal  in  every  respect. 

Dosage. — The  increase  in  the  thyroid  administration  must  be  deter- 
mined by  the  condition  of  the  patient.  As  long  as  progress  is  shown 
in  more  active  and  normal  mentality,  with  an  increase  in  the  growth 
of  the  long  bones  and  a  gradual  loss  of  the  typical  facial  and  other 


SPORADIC    CRETINISM 


447 


characteristics,  it  is  unwise  to  increase  the  dosage  of  the  thyroid. 
When,  however,  a  period  arrives  when  no  progress  appears  to  be 
made,  the  daily  dosage  should  gradually  be  increased  by  one-half 
grain.  Evidences  of  overdosage  are  pallor,  prostration,  perspira- 
tion, and  indigestion.  When  any  of  the  above  signs  present  them- 
selves, it  is  an  indication  to  discontinue  the  medication  for  twentv- 
four  hours  and  then  resume  with  smaller  doses. 

When  the  child  in  whom  treatment  was  commenced  at  the 
seventh  month  was  nine  months  of  age,  it  was  found  necessarv  to 
give  one-half  grain  three  times  daily.  One  month  later,  one-half 
grain  was  given  four  times  daily.  At  this  time  the  child  could  sit 
up  and  hold  the  head  erect.  The  increase  in  the  thyroid  extract 
produced  vomit- 
ing, and  the  dosage 
of  one-half  grain 
three  times  daih^ 
was  resumed.  One 
year  after  the  com- 
mencement of  the 
treatment,  when  the 
patient  was  nine- 
teen months  old, 
two  grains  daily 
were  required. 

In  both  of  these 
infants  the  protru- 
sion of  the  tongue 
was  one  of  the 
latest  symptoms  to 
disappear. 

My  cases  have 
varied  considerably 
as  to  the  amount  of 

thyroid  required.  The  dosage  used  was  that  taken  by  those  in  whom 
the  disease  was  discovered  very  early  in  life.  The  older  the  patient 
when  the  thyroid  is  begun,  the  less  marked  the  beneficial  results. 

I  have  a  Httle  girl  five  years  of  age  under  treatment  at  the  present 
time  who  came  under  my  care  two  years  ago,  weighing  fifteen  pounds 
and  three  ounces.  She  made  a  marvelous  improvement  under 
one-half  grain  twice  a  day,  which  in  two  weeks  was  increased  to  one- 
half  grain  three  times  a  day.  This  we  were  obliged  to  decrease 
because  of  the  prostration  and  perspiration  which  it  appeared  to 
occasion.  The  dosage  of  one-half  grain  three  times  daily  could  not 
be  used  until  she  was  four  years  of  age.  She  is  now  five  years 
old  and  requires  one  grain  three  times  a  day.  In  this  child  the 
most  remarkable  improvement  was  noted.     (See  Figs.  52  and  53.) 


Fig.  52. — Cretin,  before  Treatment. 


448  CONSTITUTIONAL   DISORDERS 

The  interval  of  time  between  the  photographs  was  thirty-four  days. 
Six  teeth  were  cut  in  three  weeks  after  beginning  the  treatment  and 
sixteen  more  were  cut  during  the  next  six  months.  The  child  made 
corresponding  improvement  in  every  other  respect. 

For  another  case,  a  nine-year-old  girl,  who  is  now  normal  in 
every  respect  except  that  her  hair  is  rather  coarse  with  a  tendency 
to  dryness  of  the  scalp,  it  was  found  that  the  following  amounts 
of  desiccated  thyroid  were  required  at  the  various  ages : 

Six  months U  grains  daily- 
One  year 3  J 

Two  years 5         "  " 

Three  years 8         "  " 

Four  years 8         "  " 

This  patient  both  walked  and  talked  at  fifteen  months.     In  her 
case,  in   order   to  deter- 
mine what  the  effects  of 
the    withdrawal    of    the 
treatment  might  be,  the 
thyroid  was  discontinued. 
This  was  first  attempted 
when   she  was   two   and 
J       -                                      l^^r       one-half    years    of    age. 
m  '     ^  '-•                         V       -  JIf          '^^^    mother   was    asked 
fl^^                                        ff  to   keep   close   watch   of 
r   W                                        S             her    in    order    to    detect 

the  slightest  difference 
in  her  behavior.  After 
three  days  without  thy- 
roid it  was  noticed  that 
the  child  became  less  ac- 
tive and  disinclined  to 
play.  She  was  not  irri- 
table or  cross,  but  would 

Fig.  53-— Cretin,  after  Thyroid  Treatment.  sit   in   her  Httlc  chair  the 

entire  day.  She  had  pre- 
viously been  very  bright,  active,  and  talkative.  A  few  days  later 
she  ceased  to  talk  voluntarily  and  answered  only  when  spoken  to. 
After  twelve  days  without  thyroid  it  was  resumed,  and  her  activity 
again  returned.  About  one  year  later  a  similar  trial  was  attempted 
with  similar  results,  although  the  duration  of  the  test  was  shorter,  as 
the  mother,  who  was  a  dispensary  patient  and  had  had  the  thyroid 
furnished  her,  purchased  a  bottle  of  tablets  and  gave  them  on  her 
own  responsibility.  The  child,  now  nine  years  old,  is  taking  twelve 
grains  daily.  She  is  a  normal,  healthy  school-girl,  alive  to  all  in- 
terests of  girlhood,  and  no  one  in  the  village  where  she  resides,  out- 
side of  the  family  circle,  knows  that  she  is  a  cretin. 


«^ 


STATUS   LYMPHATICUS.      PURPURA  449 


STATUS  LYMPHATICUS 

Status  lymphaticus  is  an  unusual  condition  in  which  the  lymph- 
atic tissue  throughout  the  body  is  in  a  state  of  hyperplasia. 
The  condition  is  usually  associated  with  marked  rachitic  manifesta- 
tions. The  chief  interest  attaching  to  the  disease  lies  in  the  dan- 
ger of  sudden  death  of  those  so  affected  and  in  the  danger  from 
the  administration  of  an  anesthetic,  particularly  chloroform.  The 
lymphatic  glands  and  the  thymus  are  the  parts  particularly  involved. 
Laryngismus  stridulus  and  thymic  asthma  are  frequent  manifestations 
of  the  condition.  It  may  exist,  however,  without  the  occurrence 
of  either.  The  nature  of  the  condition  is  not  known.  The  cases 
which  I  have  seen,  a  considerable  number,  were  all  sufferers  from 
chronic  intestinal  indigestion. 

Illustrative  Case.  —  In  one  case,  a  boy  five  months  old  —  a 
most  difficult  feeding  case  —  there  were  from  twenty  to  thirty 
attacks  of  laryngismus  stridulus  in  twenty-four  hours.  Two 
trained  nurses  were  in  constant  attendance.  The  entire  duration 
of  the  seizures  covered  a  period  of  two  months.  The  marked  fre- 
quency of  the  attacks  continued  for  less  than  a  week.  The  boy 
eventually  recovered.  When  he  was  four  years  of  age  I  removed 
both  tonsils  and  adenoids  under  ether  anesthesia  without  any 
unfavorable  effects  from  the  anesthetic. 

The  most  we  can  do  with  these  patients  is  to  improve  their 
general  condition  along  common-sense  lines  in  relation  to  nutrition, 
rest,  and  exercise,  as  described  in  the  section  on  The  Delicate  Child 
(page  142).  Excitement  and  stress  of  any  kind  are  to  be  avoided. 
In  most  instances  the  condition  disappears  under  improved  nutri- 
tion and  a  well-ordered  life. 

PURPURA 

By  purpura  we  understand  that  condition  in  which  the  blood, 
having  escaped  from  its  natural  channels,  becomes  localized  in  dif- 
ferent portions  of  the  skin  and  subcutaneous  tissue  with  no  constant 
change  in  the  character  of  the  blood  or  demonstrable  lesion  in  the 
vascular  wall.  Purpura  associated  with  scorbutus  and  peliosis 
rheumatica  has  been  referred  to  elsewhere.  Among  the  other  forms 
met  with,  the  difference  appears  to  be  largely  one  of  degree,  and 
is  due  to  toxic  conditions  of  various  kinds.  It  may  occur  late  in 
an  exhaustive  disease.  Petechiae  in  the  skin  are  frequently  seen 
at  the  close  of  many  of  the  exhaustive  diseases,  particularly  in  entero- 
colitis.    Purpura    may    result    from    the    administration    of    drugs. 

Illustrative  Cases. — One  of  my  patients  two  years  of  age  devel- 
oped a  mild  purpura  while  taking  large  doses  of  antipyrin,  which  was 
being  administered  through  a  misunderstanding.  In  pyemia,  pur- 
pura is  not  unusual.  In  a  patient  nineteen  months  of  age,  w^ho  died 
29 


450  CONSTITUTIONAL  DISORDERS 

from  a  septic  sinus  thrombosis  with  extension  to  the  jugulars,  there 
was  extensive  purpura  for  forty-eight  hours  before  death.  Blood  ex- 
aminations of  this  patient  during  life  showed  pure  cultures  of  strep- 
tococci. Another  patient,  a  boy  eight  years  of  age,  previously 
healthy,  died  in  three  days  from  purpura  fulminans  (Henoch).  In 
this  case  also,  blood  cultures  made  post  mortem,  from  subcutaneous 
hemorrhagic  areas,  showed  pure  streptococci.  In  the  severe  forms 
of  purpura  the  hemorrhage  is  not  confined  to  the  skin,  but  occurs 
from  the  mucous  surfaces  or  in  the  viscera. 

Treatment. — The  treatment  consists  in  establishing  the  vitality 
and  resistance  of  the  patient,  in  removing  the  cause  when  possible, 
and  in  the  internal  administration  of  acids  and  fruit-juices.  The 
internal  use  of  drugs,  including  the  suprarenal  extract  and  ergot, 
has  not  been  of  apparent  value  in  my  cases.  In  purpura  fulmi- 
nans the  prognosis  is  necessarily  very  grave.  When  it  develops  in 
severe  septic  conditions  or  in  prolonged  exhausting  diseases  it  is  a 
symptom  of  much  gravity.  In  these  cases,  the  free  use  of  alcoholic 
stimulation  should  be  resorted  to  early, — one  to  two  drams  being 
given  every  two  hours  to  a  child  five  years  of  age. 

HEMOPHILIA 

Hemophiha  is  characterized  by  a  tendency  to  uncontrollable 
bleeding  following  cuts  and  bruises.  The  cause  of  the  condition 
has  not  yet  been  discovered.  Various  theories  have  been  put 
forward  from  time  to  time.  Heredity  can  be  traced  in  most  cases. 
Daughters  of  bleeders  should  not  marry,  as  their  offspring  are  likely 
to  become  bleeders,  particularly'  the  male  offspring. 

Illustrative  Case. — My  personal  experience  deals  with  but  one  case, 
a  boy  who  was  under  my  care  the  greater  part  of  his  life.  The  fact 
that  he  was  a  bleeder  was  first  suggested  through  hemorrhages  into  the 
skin  about  the  knee  and  arm  which  appeared  as  soon  as  he  com- 
menced to  walk  and  to  fall  and  bruise  himself ;  in  fact,  he  was  brought 
to  my  clinic  at  the  Babies'  Hospital  Dispensary  because,  as  the 
mother  expressed  it,  he  was  continually  black  and  blue.  In  all 
other  respects  the  child  was  normal;  in  fact,  he  was  an  unusually 
strong,  well-developed  boy.  Bleeding  nearly  caused  his  death 
at  different  times  during  the  second,  third,  and  fourth  years.  A 
sUght  cut  in  the  skin  meant  days  of  bleeding.  One  particularly 
severe  and  prolonged  hemorrhage  occurred  as  the  result  of  a  fall 
when  a  tooth  pierced  the  lip.  Having  the  boy  under  observation 
for  a  long  time  and  the  assistance  of  an  intelligent  mother,  we  had 
an  opportunity  to  test  the  various  means  of  medication  and  other 
methods  of  treatment  as  suggested  by  different  authors.  Suffice 
it  to  say  that  all  measures,  both  general  and  local,  were  without 
the  slightest  benefit.  The  only  means  of  controlling  the  hemor- 
rhage was  by  the  use  of  strong  pressure  by  means  of  pads  and  sur- 


HEMOPHILIA 


451 


geon's  adhesive  plaster.  The  pressure  had  to  be  exerted  not  only 
over  the  bleeding  area  but  for  several  inches  about  it.  The  child 
passed  from  under  my  care  when  about  five  years  old,  but  I  learned 
that  he  died  soon  after  from  the  operation  of  circumcision,  which 
was  necessitated  by  the  sloughing  and  sepsis  of  the  foreskin. ' 


INFECTIOUS  FEVERS 

INFLUENZA 

The  management  of  influenza  in  a  child  is  very  similar  to  that 
of  measles.  The  disease  in  itself  is  rarely  of  suflicient  severity  to 
cause  any  great  concern.  The  possibility  of  serious  complications, 
however,  is  great;    the  younger  the  child,  the  greater  the  danger. 

Treatment. — The  disease  is  eminently  contagious.  Adults  with 
influenza  should  not  come  in  contact  with  younger  members  of  the 
family.  When  one  of  a  family  of  .children  is  attacked,  the  child 
should  be  isolated  as  if  he  had  measles  or  scarlet  fever.  The 
patient  should  be  put  on  a  reduced  diet  (see  Diet  in  Illness,  page 
133),  and  an  initial  dose  of  castor  oil  or  one  grain  of  calomel  in 
divided  doses  of  one-sixth  grain  each  should  be  administered. 

The  temperature,  which  not  infrequently  reaches  104°  F.  or 
105°  F.,  is  usually  readily  controlled  by  sponging  with  alcohol  and 
water,  one  part  alcohol  and  two  parts  water,  at  a  temperature  of 
80°  F.  I  have  never  been  obliged  to  resort  to  the  cool  pack  in 
grippe.  This,  of  course,  should  be  done  if  the  temperature  is  not 
otherwise  controlled. 

The  pain,  the  muscle  soreness,  and  the  restlessness  are  very 
much  alleviated  by  the  use  of  phenacetin,  caffein,  and  bicarbonate 
of  soda,  given  in  powders  as  follows,  to  a  child  one  year  of  age: 

I^.     Caffeinse  citratis gf-  ij 

Phenacetin gf-  v 

Sodii  bicarbonatis gr.  x 

M.     Div.  et  ft.  chart.  No.  x. 

Sig. — One  every  two  hours — eight  doses  in  twenty-four  hours. 

In  older  children,  those  from  two  to  four  years  of  age,  the  following 
may  be  used: 

I^.     Caffeinae  citratis gr-  iij 

Phenacetin gr.  x 

Sodii  bicarbonatis gr.  xx 

M.     Div.  et  ft.  chart.  No.  x. 

Sig. — One  every  two  hours — not  more  than  six  doses  in  twenty-four 
hours. 

After  the  fourth  year,  I  have  found  it  of  advantage  to  give  the 
salicylate  of  soda  instead  of  the  bicarbonate.  This,  for  a  child 
from  five  to  eight  years  of  age,  will  be  as  follows: 

3^.     Caffeinae  citratis gr.  iij 

Phenacetin gr.  xv 

Sodii  saHcylatis gr.  xxx 

M.     Div.  et  ft.  capsulse  No.  x. 

Sig. — One  capsule  every  two  hours — a  maximum  of  six  doses  in 
twenty-four  hours. 

452 


INFLUENZA  453 

The  salicylate  is  best  given  in  capsule  form,  as  most  children  at 
this  age  may  readily  be  taught  to  swallow  a  capsule. 

So  much  for  the  medication  of  the  uncomplicated  grippe  cases, 
the  duration  of  which  is  usually  from  three  to  five  days.  Such 
cases  occur  in  mild  epidemics,  in  which  the  prominent  symptoms 
are  fever,  loss  of  appetite,  headache,  prostration,  and  muscle  sore- 
ness. 

Illustrative  Cases. — Two  fatal  cases  of  grippe  in  infants,  in  which 
the  diagnosis  was  made  by  exclusion  and  verified  by  autopsy,  occurred 
at  the  Country  Branch  of  the  New  York  Infant  Asylum,  during  the 
winter  of  1888  and  1889,  which,  it  will  be  remembered,  was  the  time 
when  grippe  first  visited  this  country  in  epidemic  form.  These 
healthy,  breast-fed  babies  were  taken  with  the  disease  together 
with  about  forty  other  inmates — mothers  and  children — in  ona 
of  the  larger  wards.  The  infants  in  question,  aged  three  and  four 
months  respectively,  were  stricken  suddenly  with  high  fever  and 
marked  prostration.  They  quickly  went  into  a  condition  of  col- 
lapse and  both  died  in  less  than  thirty-six  hours  from  the  onset. 
The  autopsy  failed  to  show  any  pathologic  change  other  than  a 
slight  hypostatic  congestion  of  the  lungs. 

Complications. — The  most  frequent  complication  of  grippe  is  bron- 
chitis, and  the  most  fatal  complication  is  bronchopneumonia.  Sup- 
purative otitis  is  not  an  infrequent  complication,  or  perhaps  it  would 
be  better  to  class  it  as  a  grippe  sequela.  Among  seventy-two  cases 
of  acute  suppurative  otitis,  seen  by  me  during  the  past  two  years, 
fifty-nine,  or  81.9  percent,  occurred  with  or  followed  immediately 
upon  an  attack  of  grippe.  Patients  who,  after  an  attack  of  grippe, 
run  a  temperature  without  any  apparent  adequate  cause,  should 
always  be  examined  by  a  skilled  otologist. 

Occasionally  grippe  is  ushered  in  wdth  pronounced  gastric  dis- 
turbance. There  will  be  nausea  and  vomiting,  no  food  being  retained 
for  from  twenty-four  to  forty-eight  hours.  Pronounced  intestinal 
disturbance  is  by  no  means  an  unusual  evidence  of  infection  with 
the  influenza  bacillus;  there  may  be  diarrhea  without  any  evidence 
of  involvement  of  the  intestinal  structure,  or  there  may  be  a  colitis 
with  tenesmus  and  mucus  and  blood  in  the  stools.  In  not  a  few 
cases  the  so-called  complications  are  the  only  manifestations  of  the 
infection.  This  has  led  writers  to  describe  a  "grippe  colitis,"  a 
"grippe  gastritis,"  etc.  I  have  seen  two  cases  of  endocarditis 
associated  with  grippe. 

Regardless  of  the  way  in  which  we  interpret  these  various  condi- 
tions, one  thing  is  to  be  remembered,  that  when  the  influenza  bacillus 
plays  an  important  part  in  the  infection,  the  successful  management 
of  a  case  is  rendered  more  difficult  as  relates  to  the  ultimate  recovery 
from,  and  the  duration  of,  the  illness.  After  a  severe  so-called  grippe 
colitis,  grippe  bronchitis  or  pneumonia,  the  patient  is  left  in  a  debil- 


454  INFECTIOUS   FEVERS 

itated  condition  from  which  it  may  take  weeks  to  recover.  The 
quickest  way  to  remove  this  indefinable  "grippe  spell"  which 
rests  over  the  patient  is  by  a  change  of  climate.  Every  late  winter 
and  early  spring,  I  send  a  goodly  number  of  children  to  Atlantic 
City.  Two  or  three  weeks  there  will  do  more  to  restore  to  health 
New  York  city  patients  than  I  am  able  to  accomplish  with  drugs, 
baths,  massage,  and  diet  in  an  equal  number  of  months  at  home. 
I  have  repeatedly  seen  children  with  tracheobronchitis  with  a  nag- 
ging cough,  which  I  had  tried  in  vain  to  relieve,  cease  coughing 
within  a  very  few  days  after  reaching  that  resort. 

The  management  of  an  otitis,  pneumonia,  bronchitis,  or  colitis, 
associated  with  or  following  an  attack  of  influenza,  differs  in  no 
way,  so  far  as  the  immediate  treatment  of  the  complication  is  con- 
cerned, from  that  which  would  be  advised  if  the  case  were  inde- 
pendent of  the  influenza  bacillus.  The  case  as  a  whole,  however, 
will  require  closer  watching,  and  on  account  of  the  greater  prostration 
will  need  better  feeding  and  freer  stimulation. 

One  attack  of  grippe  confers  no  immunity  upon  the  patient ;  in 
fact,  cases  appear  to  reinfect  themselves.  For  this  reason,  I  always 
advise  that  two  rooms  be  used,  one  for  the  day  and  one  for  the 
night,  the  room  not  occupied  during  the  day  being  aired  for  several 
hours  with  all  the  windows  open.  After  recovery,  the  sick-rooms 
should  be  thoroughly  aired,  cleaned,  and  fumigated  with  sulphur  or 
chlorin  gas. 

MALARIA 

The  presence  of  the  plasmodium  malaria  in  the  blood  in  children 
should  always  be  demonstrated  before  making  a  diagnosis  of  malaria, 
as  in  this  way  only  can  it  be  definitely  determined  that  malaria 
exists.  Aside  from  the  periodicity  in  the  temperature  rise,  there 
will  usually  be  found  in  malaria  an  enlargement  of  the  spleen;  but 
bevond  this  the  symptoms  are  vague  and  indefinite.  The  diagnosis 
of  malaria  is  often  made,  and  children  are  given  quinin  when  the 
condition  does  not  exist.  According  to  my  observation,  a  periodic 
rise  in  temperature  which  does  not  respond  to  quinin  in  full  doses 
is  not  uncomplicated  malaria.  There  are  very  few  exceptions  to 
this  rule. 

Children  are  very  susceptible  to  fevers  of  a  periodic  type.  Per- 
sistent intestinal  infection,  otitis,  encapsulated  pus  in  the  pleural 
cavity,  grippe  infections,  fatigue  due  to  over-indulgence  in  play — 
any  one  of  these  conditions  mav  give  rise  to  an  elevation  of  the 
temperature  more  or  less  periodic  in  type,  covering  a  considerable 
period. 

Quinin  Administration. — When  it  is  demonstrated  that  malaria 
exists,  quinin  should  be  given  in  what  might  be  considered  large 
doses,  if  we  are  to  use  the  adult  for  comparison.  Children  tolerate 
quinin  well;  in  fact,  to  be  effective,  a  much  larger  amount  compara- 


MALARIA  455 

lively  is  required  than  in  adults.  In  giving  quinin  to  young  chil- 
dren, care  must  be  used  in  its  administration  lest  it  excite  vomit- 
ing. I'^or  this  reason  it  should  be  given  after  meals  in  solution  or 
in  capsule.  The  best  menstruum  is  a  preparation  of  yerba  santa 
known  as  yerberzine.'  A  child  under  eighteen  months  of  age  will 
require  from  eight  to  twelve  grains  daily.  Two  to  three  grains  of 
the  bisulphate  should  be  given  at  a  dose,  not  more  than  four  doses 
being  given  in  twenty-four  hours. 

When  resident  physician  at  The  New  York  Infant  Asylum,  then 
located  in  southern  Westchester  County,  New  York,  there  was  a 
great  deal  of  malaria  among  the  women  and  children  inmates.  In 
that  institution  I  have  repeatedly  given  infants  under  four  months 
of  age  eight  grains  in  twenty-four  hours.  In  some  cases  at  this 
age  a  larger  quantity— ten  to  twelve  grains — will  be  required. 
Quinin  chocolate  tablets  are  sometimes  used  in  giving  the  drug 
to  children.  In  using  these  tablets  it  must  be  remembered  that 
the  quinin  in  them  is  in  the  form  of  the  tannate,  and  that  one  grain 
of  the  tannate  represents  about  one-third  of  a  grain  of  the  sulphate. 
In  order  to  give  sufhcient  quinin  in  this  form  to  be  of  value,  the 
large  amount  of  chocolate  in  the  tablet  is  sure  to  upset  the  digestion. 
In  children  under  one  year  of  age  with  whom  yerberzine  may  dis- 
agree because  of  the  sugar  which  it  contains,  the  bisulphate  may 
be  given  in  solution  in  distilled  water,  followed  by  a  teaspoonful 
of  orange-juice.  In  older  children — those  from  two  to  six  years 
of  age — from  fifteen  to  thirty  grains  daily  will  be  necessary  to  con- 
trol the  disease.  Here,  as  in  the  younger  children,  it  is  given  in 
yerberzine  unless  the  child  can  be  taught  to  take  a  capsule,  when 
it  is  given  in  three-grain  doses  at  two-hour  intervals  until  the  pre- 
scribed daily  amount  has  been  taken. 

The  giving  of  a  large  dose  of  quinin  a  few  hours  preceding  the 
expected  chill  does  not  answer  well  in  children,  as  a  large  amount 
given  at  one  time  is  liable  to  cause  vomiting. 

The  use  of  quinin  by  inunction  or  by  the  rectum  has  not  been 
satisfactory.  Its  use  was  so  attempted  at  the  Infant  Asylum  in 
a  great  many  cases  where  difficulty  was  experienced  in  the  stomach 
administration. 

In  but  one  case,  aged  two  years,  have  I  been  obliged  to  resort 
to  hypodermic  medication.  The  child  showed  the  tertian  parasite, 
and  the  disease  resisted  the  internal  use  of  quinin  in  large  doses, 
but  responded  promptly  to  the  muriate  of  quinin  given  hypoder- 
matically,  seven  grains  being  used  at  one  injection.  There  was  no 
abscess  at  the  site  of  the  injection  and  the  child  was  permanently 
cured.  To  be  sure,  the  administration  of  quinin  was  continued  by 
the  mouth,  but  the  dosage  of  sixteen  grains  daily  was  now  appar- 
ently effective  where  previously  it  had  made  no  impression. 
'  Made  by  Lilly  and  Co. 


456  INFECTIOUS  FEVERS 

Recurrence. — The  use  of  quinin  in  malaria  should  not  be  stopped 
abruptly  with  a  cessation  of  the  fever.  It  is  my  custom  to  give 
it  in  full  doses  for  one  week  after  the  temperature  fails  to  rise,  unless 
there  is  a  subnormal  temperature,  in  which  event  it  is  reduced  one- 
half  or  temporarily  discontinued.  It  is  a  difficult  matter  to  determine 
when  a  case  of  malaria  is  cured.  Time  and  again  I  have  supposed 
that  a  patient  was  well  when  a  recurrence  of  the  paroxysms  took 
place  weeks  afterward.  How  much  of  this  was  due  to  reinfection, 
and  how  much  to  the  old  infection  which  had  not  been  entirely 
eradicated,  is  difficult  to  say.  I  am  inclined  to  the  belief,  however, 
that  in  many  instances  the  plasmodium  had  remained  inactive 
in  the  spleen  in  spite  of  its  return  to  nearly  its  normal  size,  for  the 
reason  that  the  recurrence  of  symptoms  sometimes  took  place 
coincident  with  some  other  illness  with  fever,  such  as  tonsillitis  or 
acute  indigestion.  My  experience  with  recurrences  of  the  disease 
has  been  such  that  after  an  attack  of  malaria  I  now  direct  that  the 
child  be  given  quinin  for  one  week  out  of  each  month,  for  an  indefinite 
time,  at  least  for  a  year  following  the  original  attack.  In  a  com- 
paratively recent  case,  a  girl  five  years  of  age  had  repeated  attacks 
for  two  years  before  coming  under  my  care.  The  mother  was 
instructed  to  give  the  child  twelve  grains  of  the  bisulphate  daily 
for  seven  days  out  of  each  month.  This,  without  a  change  of  resi- 
dence, was  sufficient  to  prevent  a  recurrence  during  the  fifteen 
months  which  followed. 

TYPHOID  FEVER 

Typhoid  fever  is  a  rare  disease  in  New  York  city  children  under 
two  years  of  age.  I  have  been  able  to  prove  but  two  cases  in  children 
under  one  year.  One  was  ten,  the  other  eight  months  of  age.  The 
diagnosis  is  often  difficult  because  of  the  absence  of  the  symptoms 
seen  in  the  adult.  The  younger  the  child,  the  more  likely  is  this 
to  be  the  case.  In  neither  of  the  above  cases  could  we  have  been 
positive  of  typhoid  without  the  aid  of  the  Widal  reaction.  While 
usually  the  disease  runs  a  shorter  course  in  the  child  than  in  the 
adult,  an  attack  means,  at  the  least,  several  days  of  illness,  and  it 
may  mean  from  three  to  six  weeks.  For  this  reason  it  is  best  to 
establish  a  sick-room  regime,  under  which  must  be  particularly 
considered  the  feeding,  the  bathing,  the  airing  of  the  room,  and 
absolute  quiet  for  the  patient.  The  bed-linen  should  be  changed 
every  day,  and  if  the  patient  becomes  very  ill,  but  one  attendant 
at  a  time  should  be  in  the  sick-room. 

Bathing. — The  typhoid  patient  should  be  sponged  twice  a  day, 
an  ordinary  cleansing  bath  being  given.  During  the  bath,  it  is 
not  necessary  to  uncover  the  patient.  Parts  of  the  body  may  be 
bathed  and  dried,  when  other  parts  may  be  given  attention. 

Mouth  Toilet. — Careful  mouth  toilet  should  be  observed  in  typhoid 


TYPHOID    FEVER  457 

fever  in  children.  Gingivitis  and  ulcerative  stomatitis  with  sec- 
ondary cervical  lymph-node  involvement  are  not  infrequent  com- 
plications of  these  cases. 

Care  of  the  Discharges. — The  discharges  from  both  bladder 
and  intestine  should  be  received  in  vessels  containing  a  i  :  looo 
solution  of  bichlorid  of  mercury.  Carbolic  acid  should  not  be  used. 
The  necessity  for  the  attendants  to  wash  their  hands  with  soap 
and  water  after  attending  to  the  patient  should  be  made  very 
plain.  They  should  also  be  advised  as  to  the  proper  disposal  of 
the  discharges.  In  children  of  tender  age  who  still  require  the 
napkin,  it  is  best  to  dispense  with  the  usual  article  and  use  cheese- 
cloth instead,  several  thicknesses  of  which  may  be  made  of  the 
required  shape  and  burned  when  soiled. 

The  Feeding  of  Typhoid  Fever  Cases. — Contrary  to  the  general 
practice,  I  give  little  or  no  milk  in  typhoid  cases.  Karly  in  my 
professional  work  I  gave  milk,  which  I  had  been  taught  was  the 
only  diet  for  the  typhoid  patient.  I  soon  discovered  that  the  less 
milk  was  given,  the  less  the  tympanites.  I  found  that  without 
milk  the  temperature  ran  lower,  that  there  was  less  tendencv  to 
delirium,  that  the  duration  of  the  case  was  shorter  and,  as  a  whole, 
less  severe. 

The  diet  which  I  now  use  consists  largely  of  gruels  made  from 
cracked  wheat,  barley,  rice,  oatmeal,  or  any  of  the  uncooked  cereals 
by  boiling  for  three  hours  one  ounce  of  the  cereal  in  one  pint  of  water. 
At  the  completion  of  the  boiUng,  boiled  water  is  added  to  make 
the  quantity  of  the  gruel  one  pint.  If  the  gruel  is  too  thick  for 
drinking,  boiled  water  may  be  added.  The  gruel  thus  prepared  is 
used  as  a  "stock."  It  may  be  given  plain,  with  salt  or  with  sugar 
or  both.  I  frequently  add,  as  flavoring,  two  or  three  ounces  of 
chicken  or  mutton  broth.  From  six  to  eight  ounces  of  the  gruel  are 
given  every  three  hours — five  to  six  feedings  in  the  twenty-four 
hours.  The  patient  is  encouraged  to  drink  water,  which  is  given 
between  feedings.  Lemonade,  tea,  and  weak  coffee  may  also  be 
given  between  the  feedings.  In  the  event  of  abdominal  distention 
under  the  carbohydrate  diet,  the  gruel  is  dextrinized  by  the  addi- 
tion of  "Cereo,"  one  teaspoonful  to  a  pint  of  gruel.  The  gruel  should 
be  at  a  temperature  of  about  140°  F.  when  the  Cereo  is  added. 

When  the  temperature  shows  a  tendency  toward  a  lower  level  in 
or  at  the  end  of  the  third  week,  zwieback  and  toast  are  added  to  the 
diet.  Later,  when  the  tongue  becomes  clear  and  the  breath  loses 
its  characteristic  odor,  kumyss,  matzoon,  skimmed  milk,  scraped  rare 
beef,  and  soft-boiled  eggs  are  allowed.  With  the  use  of  the  more 
substantial  foods,  the  number  of  feedings  in  the  twenty-four  hours 
is  reduced  to  four. 

Milk  should  not  be  given  in  any  considerable  amount  before  the 
temperature  has  been  normal  for  one  week.  Even  then,  in  a  case 
which  has  had  no  milk  or  has  had  pronounced  elevation  of  tempera- 


458  INFECTIOUS   FEVERS 

ture  and  intestinal  disturbance,  the  giving  of  milk  may  cause  a  rise 
in  the  temperature.  In  not  a  few  cases  in  which  the  temperature 
was  running  a  low  course — from  ioo°  to  102°  F. — without  tympanites 
or  delirium,  I  have  seen  it  shoot  up  to  105. 5°  F.,  with  furred  tongue 
and  distended  abdomen,  as  a  result  of  the  administration  of  milk, 
which  was  usually  given  at  the  solicitation  of  friends,  who  feared  the 
patient  was  being  starved ! 

Illustrative  Case. — A  few  years  ago  a  girl,  twelve  years  of  age, 
had  typhoid  fever.  The  temperature  was  not  high,  the  range  being 
from  101°  to  103°  F.  In  fact,  fever  and  an  enlarged  spleen  were  the 
only  signs  of  the  disease,  until  the  diagnosis  was  confirmed  by  a 
positive  Widal  reaction.  The  tongue  was  moist  throughout,  as  is  not 
unusual  when  milk  is  not  given.  The  family  were  fearful  that 
the  patient  was  not  being  sufficiently  nourished.  The  mother 
had  been  told  by  a  physician,  a  family  friend,  that  such  was  the 
case.  She  begged  that  I  allow  the  girl  one  glass,  eight  ounces, 
of  full  milk  daily.  I  immediately  ordered  the  nurse  to  give  the 
patient  one  glass  of  Walker-Gordon  milk  once  in  twenty-four  hours. 
She  did  so,  and  in  three  hours  after  the  first  glass  the  temperature 
had  risen  to  106°  F.,  with  abdominal  pain  and  distention.  One 
bottle  of  the  citrate  of  magnesia  and  a  high  enema  were  given,  after 
which  the  disease  resumed  its  usual  course  on  the  previous  diet, 
without  milk,  the  temperature  not  going  above  99°  F.  after  the 
seventeenth  day.     An  uneventful  convalescence  followed. 

Drugs. — With  the  so-called  intestinal  antiseptics  in  typhoid  fever, 
my  experience  has  been  most  unsatisfactory,  so  far  as  concerns  their 
influence  upon  the  disease.  If  there  is  constipation,  the  citrate  of 
magnesia,  from  four  to  six  ounces,  given  cold,  is  grateful  to  the 
patient  and  usually  answers  the  purpose  well.  If  the  bowels  do 
not  move  once  in  twenty-four  hours,  a  high  enema  should  be  given. 
The  digestive  capacity  is  indicated  by  the  condition  of  the  tongue 
and  may  be  improved  by  the  use  of  dilute  hydrochloric  acid  and 
the  tincture  of  nux  vomica.  The  following  will  be  suitable  for  a 
child  from  five  to  ten  years  of  age: 

I^.     Tincturse  nucis  vomicae gtt.  xlviij 

Acidi  hydrochlorici  diluti gtt.  cxx 

Glycerini o  iss 

Aquae  destillatae q.  s.  adgiv 

M.     Sig. — One  teaspoonful  after  each  meal. 

There  may  be  as  many  as  four  bowel  passages  in  twenty-four 
hours  without  harm  to  the  patient.  In  fact,  I  consider  from  two 
to  four  necessary  to  maintain  free  drainage.  When  there  are  more 
than  six  in  twenty-four  hours,  loose  and  watery  in  character,  the 
loss  of  fluids  sustained  may  be  a  serious  factor  in  the  case,  in  caus- 
ing a  concentration  of  the  blood,  with  a  corresponding  concentration 
of  the  poison,  as  shown  in  the  marked  general  toxemia. 


TYPHOID   FEVER  459 

Diarrhea  in  typhoid  is  best  controlled  by  the  use  of  opium  com- 
bined with  bismuth.  For  a  child  from  three  to  five  years  of  age, 
the  following  may  be  given : 

I^.     Pulveris  Doveri gr.  x 

Bismuthi  subnitratis gr.  c 

(Squibb) 
M.     Div.  et  ft.  chart.  No.  x. 

Sig. — One  every  three  hours  until  the  stools  diminish  in  frequency, 
when  they  may  be  given  at  intervals  of  from  six  to  twelve 
hours. 

.  In  children  from  one  to  three  years  old,  the  dose  of  the  Dover's 
powder  should  be  reduced  one-half,  the  full  amount  of  the  bismuth 
being  given.  The  amount  required  to  keep  the  diarrhea  under 
control  will  soon  be  learned.  Of  course,  constipation  must  not  be 
produced.  If  a  free  bowel  action  is  interfered  with,  there  will  be 
increased  prostration  and  higher  temperature. 

Control  of  the  Fever. — A  temperature  at  or  below  104°  F.  is  not 
interfered  with,  in  the  great  majority  of  cases.  Of  course,  a  very 
delicate  child  with  a  weakened  heart  action  may  require  the  use 
of  antipyretic  measures  before  this  temperature  is  reached.  This 
necessity,  however,  is  unusual.  My  observation  is  that  when  above 
104°  F.  the  patient  does  better  if  proper  means  are  used  to  control 
the  temperature. 

Antipyretic  Drugs. — Antipyretic  drugs  are  rarely  given.  Quinin 
in  my  cases  has  never  proved  to  be  of  the  slightest  value,  even 
when  given  in  large  doses — fifteen  or  twenty  grains  in  twenty-four 
hours — to  a  child  five  years  of  age.  The  coal-tar  products,  such 
as  phenacetin,  may  be  used  in  small  doses  without  harm,  if  hydro- 
therapy is  not  applicable,  as  in  a  case  which  I  recently  saw  in  a 
remote  country  district.  The  patient  was  a  boy  six  years  of  age. 
He  was  delirious  at  times,  with  almost  constant  tossing  about  the 
bed,  sleeping  but  little,  with  a  temperature  ranging  from  105°  to 
106°  F.  The  disease  was  in  the  latter  part  of  the  second  week  and 
the  patient  was  becoming  rapidly  exhausted.  The  parents,  densely 
ignorant,  refused  to  allow  the  bath  or  pack.  The  sponging,  which 
was  carried  out  indifferently,  had  not  the  slightest  effect  on  the 
temperature  and  appeared  to  excite  the  patient.  It  was  suggested 
to  the  attending  physician  that  he  give  two  grains  of  phenacetin 
and  one-half  grain  of  the  citrate  of  caffein  at  intervals  of  from  three 
to  six  hours.  It  was  found  that  from  four  to  six  powders  daily  were 
required  to  keep  the  fever  within  the  desired  bounds  and  the  skin 
moist.  They  had  also  a  decidedly  quieting  effect  upon  the  patient, 
whose  heart  action  was  in  no  way  unfavorably  influenced  and  who 
made  a  complete  recovery.  Had  the  great  restlessness,  the  loss 
of  sleep,  and  the  delirium  continued,  I  have  no  doubt  but  that 
there  would  have  been  a  fatal  termination. 

While  there  is  much  truth  in  what  has  been  written  as  to  the 


46o  INFECTIOUS  FEVERS 

depressing  effects  of  the  coal-tar  products,  and  while  the  dangers 
from  their  excessive  use  are  realized,  there  are  occasions  where  they 
are  a  necessity,  and  I  cannot  help  feeling  that  the  dangers  have 
been  exaggerated.  Probably  the  diseases  in  which  their  use  is  most 
dangerous  are  pneumonia  and  the  inflammatory  conditions  of  the 
heart. 

Hydrotherapy. — Pyrexia  is  best  controlled  by  hydrotherapy. 
Sponging  with  lukewarm  or  cool  water  may  be  tried,  and  if  the  case 
is  not  a  severe  one,  this  may  answer.  The  child  may  be  sponged 
with  water  at  from  70°  to  80°  F.  for  one-half  hour  out  of  every 
two  or  three  hours.  Sponging,  however,  even  if  it  controls  the 
temperature,  may  not  be  the  best  means  of  using  water  for  this 
purpose,  for  the  reason  that  many  children  object  to  it,  and  in  con- 
sequence the  sponging  disturbs  them,  increasing  their  irritability 
and  reducing  their  vitality.  The  use  of  the  bath  for  the  reduction 
of  fever  in  children  I  have  discontinued.  They  invariably  object 
to  it,  the  bath  excites  or  frightens  them,  and,  as  a  rule,  particularly 
in  the  very  young  and  delicate,  the  reaction  following  it  is  poor. 
Moreover,  the  bath  necessitates  a  great  deal  of  handling,  undressing 
and  dressing,  and  therefore  tires  the  patient.  Reduction  of  the 
temperature  by  means  of  a  rectal  irrigation  with  cool  water  has  its 
advocates.  If  the  temperature  is  running  high  and  intestinal 
lavage  is  indicated  for  reasons  other  than  the  temperature,  it  may 
be  used  here,  the  water  being  of  a  lower  temperature  than  that  of 
the  body,  though  I  never  use  it  lower  than  80°  F.  for  this  purpose. 
Without  a  high  body-temperature,  however,  and  other  indications 
as  well,  it  is  never  to  be  used.  It  causes  straining,  excites  the  child, 
and  thus  increases  the  danger  of  hemorrhage  and  perforation. 
Furthermore,  it  is  a  very  indifferent  antipyretic,  even  when  used 
with  water  as  cold  as  75°  F.  By  far  the  best  means  of  reducing 
the  temperature  in  children  is  the  use  of  the  cool  pack  (page  481). 
Its  advantages  are  that  it  causes  no  fright  or  shock,  the  child  being 
disturbed  comparatively  little  by  it.  He  may  be  placed  in  a  towel, 
which  has  been  w^et  with  water  at  95°  F.,  and  the  only  manipulation 
necessary  is  to  turn  him  from  side  to  side,  so  that  the  towel  may 
be  kept  constantly  wet  with  the  cool  water  at  the  desired  temperature. 
The  pack  more  effectually  controls  the  temperature  than  does  either 
sponging  or  the  tub-bath,  and  it  is  thus  kept  within  the  desired 
hmits.  As  suggested  elsewhere  (see  page  272),  the  child  should  be 
removed  from  the  pack  when  his  temperature  reaches  102°  F. 

Heart  Stimulants. — If  the  heart  by  the  rapidity  of  its  action  shows 
signs  of  failure,  the  tincture  of  strophanthus  is  our  best  remedy. 
When  there  is  irregularity  in  force  and  rhythm,  strychnin  should  be 
used.  A  child  from  five  to  ten  years  of  age  may  be  given  two  drops 
of  the  tincture  of  strophanthus  at  intervals  of  from  two  to  four  hours. 
Strychnin,  y^-q  grain  at  intervals  of  from  three  to  four  hours,  may  be 


ERYSIPELAS  461 

given  for  the  same  age.  Alcohol  should  not  be  given  as  a  heart 
stimulant  until  other  means  have  failed.  It  is  a  drug  to  be  used 
only  in  conditions  of  great  stress.  Its  function  is  to  carry  us  over 
and  out  of  difficult  places,  and  it  may  be  given  in  the  form  of 
whisky  or  brandy,  one  to  three  drams  at  intervals  of  from  two  to 
four  hours  in  children  from  three'  to  ten  years  of  age.  Its  con- 
tinued administration  for  a  considerable  period  is  not  to  be  ad- 
vised. In  any  disease  it  is  difficult  to  lay  down  definite  rules  for  the 
administration  of  heart  stimulants.  They  are  used  with  the  hope 
of  producing  a  definite  effect,  and  when  such  effects  are  produced,  a 
larger  quantity  should  not  be  given.  It  is  best  always  to  begin 
with  small  doses  and  gradually  increase  until  the  desired  results  are 
apparent. 

Hemorrhage  and  Perforation. — Hemorrhage  has  not  occurred 
in  any  of  my  cases  which  were  given  the  non-milk  diet.  Should  it 
occur,  the  cold  coil  or  the  ice-bag  should  be  applied  and  Dover's 
powder  given  in  full  doses  to  control  peristalsis.  In  case  of  per- 
foration, operative  procedures  are  to  be  resorted  to,  but  these  hold 
out  little  hope.  Children  bear  abdominal  operations  badly,  and, 
considering  the  exhausted  condition  of  a  young  child  in  the  third 
or  fourth  week  of  a  severe  typhoid,  the  outlook  is  most  unfavorable. 

ERYSIPELAS 

Erysipelas  is  a  particularly  fatal  disease  in  infants.  In  the 
new-born,  95  percent  of  the  cases  are  fatal.  Fifty  percent  of  my 
cases  occurring  in  children  under  one  year  of  age  have  been  fatal. 
When  the  streptococcus  of  erysipelas  gains  entrance  into  the  skin 
of  an  infant,  it  is  unusual  if  the  entire  skin  surface  does  not  become 
involved  before  the  process  subsides.  The  long-continued  high 
temperature,  the  toxemia,  the  discomfort  from  the  inflammation, 
and  the  interference  with  nutrition  greatly  reduce  the  patient,  and 
if  he  resists  the  disease  during  the  acute  stage  he  is  very  apt  to  die 
later  from  exhaustion.  This  was  the  outcome  in  four  cases  seen 
within  the  past  three  months  at  The  New  York  Infant  Asylum, 
where  each  child  went  through  the  active  period  of  the  disease, 
but  died  a  week  or  two  afterward  from  exhaustion  and  marasmus. 

Treatment. — The  treatment  is  unsatisfactory,  particularly  so  in 
young  children — the  younger  the  child,  the  graver  the  prognosis — and 
absolutely  nothing  is  to  be  promised.  I  have  employed  scarifications 
in  advance  of  the  line  of  the  slowly  creeping  inflammation,  and 
whether  solutions  of  the  bichlorid  of  mercury,  carbolic  acid,  or 
ichthyol  were  used  as  a  dressing,  I  have  seen  the  red  line  pass  the 
scarified  disinfected  surface  regardless  of  the  nature  of  the  antiseptic 
and  regardless  of  the  vigor  and  vitality  of  the  child.  The  termination 
of  the  cases,  whether  in  recovery  or  death,  depends  to  a  great  extent 
upon  the  resistance  of  the  patient  and  the  severity  of  the  infection, 


462  INFECTIOUS   FEVERS 

SO  that  our  first  step  should  be  to  place  the  child  in  the  best  position 
to  resist  the  disease. 

Hygiene. — One  of  the  first,  perhaps  the  most  important  factor 
in  the  treatment  of  these  cases  is  abundance  of  fresh  air.  In 
the  winter  the  child  does  best  when  placed  in  a  room  with  windows 
wide  open,  not  for  a  few  moments  but  continuously.  Protected  with 
hot-water  bags  and  sufficient  clothing,  there  is  no  danger,  as  long 
as  the  temperature  of  the  room  does  not  fall  below  55°  F.  At 
other  seasons  of  the  year  the  patients  should,  if  possible,  be  kept 
out  of  doors. 

Infants  with  erysipelas  are  particularly  liable  to  develop  gastro- 
enteric disorders.  In  case  the  child  is  bottle-fed,  the  milk  mixture 
should  at  once  be  reduced  from  50  to  75  percent  by  the  addition  of 
barley-water  or  Granum-water,  No.  i ,  so  that  the  amount  of  fluid 
given  at  a  feeding  remains  unchanged. 

Internal  medication  such  as  I  have  used  has  been  of  no  value  aside 
from  its  stimulating  or  sustaining  nature.  The  tincture  of  the  muriate 
of  iron  is  not  to  be  given  young  infants  with  erysipelas.  It  almost 
invariably  disturbs  the  appetite  and  interferes  with  the  digestion. 

Local  Applications. — The  local  measure  which  is  unquestionably 
of  some  value  is  the  use  of  ichthyol.  I  prefer  a  10  percent  solution, 
if  the  involved  area  is  one  or  more  of  the  extremities  or  a  small  por- 
tion of  the  trunk.  Solutions  as  dressings  should  not  be  used  in  infants 
when  the  erysipelatous  process  involves  the  face  or  much  of  the 
trunk.  When  these  parts  are  involved,  a  dressing  of  30  percent 
ichthyol  ointment  in  vaselin  is  applied  on  strips  of  lint  or  linen  and 
renewed  everv  three  hours.  The  frequent  renewal  is  important,  and 
the  ointment  dressing  should  be  used  only  on  the  acutely  involved 
areas.  When  in  a  given  case  the  inflammation  begins  to  subside,  the 
dressings  should  be  removed  and  the  parts  bathed  freely.  It  must 
be  remembered  in  this  connection  that  the  skin  is  an  important  organ 
of  excretion,  particularly  of  carbon  dioxid.  The  constant  covering 
of  comparatively  large  surfaces  on  a  small  child,  interfering,  as  it 
does,  with  the  function  of  the  skin,  may  become  a  serious  matter. 
The  local  treatment  with  ichthyol  should  follow  up  the  extension 
of  the  inflammatory  process  and  be  continued  until  it  subsides. 

Stimulants. — Nearly  every  infant  with  erysipelas  will  require  stim- 
ulation. For  this  purpose  small  doses  of  whisky  well  diluted  appear 
to  answer  best.  From  five  to  fifteen  drops  at  two-hour  intervals  for 
children  under  two  years  of  age  have  aided  me,  I  am  sure,  in  carry- 
ing the  patient  through  to  a  successful  convalescence. 

Erysipelas  is  the  only  disease  in  which  it  is  wise  to  use  alcohol  as 
an  early  and  oftentimes  the  only  stimulant.  When  the  inflammation 
subsides  the  child  is  by  no  means  to  be  regarded  as  well.  In  the 
absence  of  sequelae,  such  as  a  phlegmon,  an  endocarditis,  or  nephritis, 
the  vitality  may  have  become  so  reduced  that  sudden  death  may 


RHEUMATISM  463 

take  place  when  it  is  thought  that  the  patient  is  well  on  the  road 
to  recovery,  such  a  result  being  due,  perhaps,  to  an  unrecognized 
myocarditis.  During  the  entire  attack,  and  throughout  convales- 
cence, the  child  should  be  fed  to  the  limit  of  his  digestive  capacity, 
never  beyond  it.  This  can  be  done  only  by  careful  observation  of  the 
case  and  frequent  inspection  of  the  stools. 

In  the  event  of  high  temperature,  above  104°  F.,  the  cool  pack 
(page  481)  may  be  effectively  used. 

RHEUMATISM 

Rheumatism  is  an  exceedingly  rare  disease  in  children  under 
two  years  of  age.  It  is  occasionally  seen  in  those  between  the 
second  and  fourth  years  and  is  of  very  frequent  occurrence  after 
the  fourth  year. 

The  manifestations  of  rheumatism  in  children  are  many.  Prob- 
ably its  most  frequent  manifestation  is  in  the  catarrhal  inflamma- 
tory conditions  of  the  respiratory  tract  and  in  indefinite  muscle 
pains,  commonly  known  as  growing  pains.  Inflammatory  conditions 
of  the  upper  respiratory  tract,  particularly  such  as  relate  to  the 
mucous  membrane  of  the  throat  and  the  tonsils,  in  a  majority 
of  instances  are  due,  probably,  to  a  rheumatic  infection. 

In  children,  involvement  of  the  joints  is  also  a  result  of  rheumatic 
infection,  but  there  is  less  tendency  to  joint  involvement  in  them 
than  in  adults. 

During  the  past  twelve  months  I  have  had  four  cases  of  pleurisy 
with  effusion  of  rheumatic  origin.  The  rheumatic  state  or  habit, 
whatever  it  may  be  called,  is  treated  by  physicians  generally  with 
entirely  too  little  concern. 

Endocarditis  is  a  frequent  manifestation  of  rheumatism — a 
part  of  the  disease  and  not  a  complication.  Some  of  my  most 
severe  cases  of  endocarditis  have  shown  the  most  trivial  joint  and 
muscle  symptoms.  In  other  cases  there  has  been  endocarditis 
without  a  single  joint  or  muscle  symptom.  Usually  those  children 
of  rheumatic  inheritance  whom  we  question  closely,  we  shall  find 
have  had  more  than  their  share  of  tonsillitis  and  sore  throat.  It 
is  the  strong  tendency  to  heart  involvement  in  rheumatic  children 
that  should  mark  any  child  so  affected  as  an  object  for  special 
prophylactic  care. 

Children  with  growing  pains  or  with  respiratory  indications 
of  rheumatism,  such  as  repeated  bronchitis  and  asthma,  with  or 
without  a  pronounced  rheumatic  history,  should  receive  prompt 
treatment  for  the  condition.  For  although  we  beheve  the  acute 
inflammatory  involvement  of  the  heart  and  joints  to  be  of  bacterial 
origin,  nevertheless,  before  infection  takes  place,  there  must  be 
a  favorable  field  for  the  development  of  the  specific  bacteria,  if  there 
are  such,  to  operate  in.     The  peculiar  condition  of  the  blood  and 


464  INFECTIOUS   FEVERS 

tissues,  that  something  which  favors  a  fertile  field  for  the  specific 
bacteria,  may  be  the  result  of  heredity  or  of  errors  in  living,  particu- 
larly as  relates  to  the  diet.  In  any  event,  proper  feeding  and  appro- 
priate dietetic  regulation  will  change  this  receptive  state  to  one  of 
apparent  health.  This  is  proved  by  the  relief  furnished  to  children 
who  have  suffered  much  from  growing  pains,  and  by  a  reduction  of 
from  60  to  80  percent  in  the  number  of  attacks  during  the  year  of 
inflammatory  throat  conditions. 

It  will  usually  be  found  that  rheumatic  children  combine  one 
or  two,  or  perhaps  all,  of  the  following  conditions:  They  have  a 
rheumatic  inheritance,  they  habitually  indulge  to  excess  in  sweets — 
by  which  I  mean  sugar  in  any  form — and  a  considerable  part  of 
their  daily  food  is  red  meat. 

Treatment. — Diei. — My  first  step  in  the  management  of  a  case  of 
this  nature  is  to  eliminate  red  meat  from  the  diet  for  ten  days  or 
two  weeks.  A  minimum  amount  of  sugar  is  given,  just  enough  to 
make  the  food  palatable.  In  a  case  which  resists  treatment,  or  when 
there  is  a  rheumatic  inheritance,  saccharin  is  substituted  for  sugar. 
The  child  is  encouraged  to  eat  freely  of  green  vegetables.  The  use 
of  potatoes  boiled  with  the  skins  on  is  encouraged.  Fish,  eggs, 
and  poultry  are  allowed  as  usual.  In  order  that  the  child  may 
not  suffer  from  the  removal  of  a  large  amount  of  proteid  from  the 
diet,  cereals  and  legumes  rich  in  proteid  are  given.  Particularly 
useful  in  this  condition  is  plain  oatmeal,  which,  of  course,  should 
be  cooked  three  hours.  Dried  peas,  beans,  and  lentils  are  given 
in  the  form  of  a  puree. 

Drugs. — In  addition  to  these  changes  in  the  diet,  a  child  of 
from  five  to  ten  years  of  age  is  given  ten  grains  of  bicarbonate  of 
soda,  three  hours  after  breakfast  and  dinner  for  one  week,  and 
five  grains  three  hours  after  each  meal  for  the  second  week, 
after  which  time  he  is  given  five  grains  of  the  bicarbonate  of  soda 
twice  daily  for  five  days,  with  a  ten-day  intermission,  when  the 
dosage  is  repeated.  For  six  weeks  the  soda  is  used  in  this  way— for 
five  days  with  ten  days'  intermission.  The  low  sugar  and  the  low 
meat  diet  should  be  continued  indefinitely  if  there  is  a  rheumatic 
history,  or  if  the  child  has  had  repeated  rheumatic  attacks,  whether 
such  manifestations  have  been  in  the  throat,  in  the  muscles,  or  in 
the  joints.  The  mother  should  be  instructed  to  resume  the  bicar- 
bonate of  soda  with  the  first  complaint  of  pain  on  the  part  of  the 
child.  If  the  growing  pains  continue  in  spite  of  the  diet  and  the 
bicarbonate  of  soda,  five  grains  of  the  salicylate  of  soda  should  be 
given  after  each  meal,  the  use  of  the  bicarbonate  being  continued. 
It  is  not  wise  to  continue  the  salicylate  after  the  acute  symptoms 
have  subsided. 

Children  who  are  subject  to  frequent  attacks  of  rhinitis,  tonsilHtis, 
and  angina,  with  or  without  a  rheumatic  history,  should  indulge 


RHEUMATISM  465 

Sparingly  in  red  meat,  never  more  than  once  a  day,  better  every 
second  day.  Only  sufficient  sugar  to  make  the  food  palatable  should 
be  allowed.  The  use  of  candy  should  be  reserved  for  very  rare 
occasions.  A  warm  bath  should  be  given  at  night,  followed  by  a 
generous  friction  of  the  skin  in  drying. 

Illustrative  Case. — Asthmatic  bronchitis  is  usually  dependent 
upon  the  rheumatic  state.  Repeated  attacks  suggest  the  possibility 
of  their  being  of  rheumatic  origin.  A  Httle  girl  eight  years  old  was 
brought  to  my  office  about  a  year  ago,  because  of  repeated  attacks 
of  bronchitis.  The  mother,  a  woman  of  unusual  education  and 
refinement,  stated  that  the  child  had  had  an  average  of  two  attacks 
of  bronchitis  monthly  during  the  previous  year,  and  at  least  pne 
every  month  since  she  was  five  years  of  age.  On  my  expressing 
some  doubt  as  to  the  frequency,  she  stoutly  maintained  that  her 
statement  was  correct.  The  family  lived  in  Brooklyn  and  had  been 
told  that  the  child  could  not  remain  there  during  any  portion  of  the 
year.  She  had  spent  the  colder  months  at  different  winter  resorts, 
with  very  little,  if  any,  resultant  effect  upon  the  severity  or  fre- 
quency of  the  attacks.  The  child  was  pale  and  inclined  to  stoutness. 
There  had  been  no  other  illness  of  consequence.  The  attacks  were 
peculiar  in  that  they  were  of  short  duration  but  very  severe.  There 
usually  was  a  temperature  range  from  100°  to  101°  F.  There  were 
cough  and  difficulty  in  breathing  with  occasional  attacks  of  marked 
air  hunger.  The  attacks  were  always  accompanied  by  severe 
coryza.  She  came  to  me  at  the  end  of  an  attack.  An  examination 
of  the  chest  showed  throughout  a  fairly  even  distribution  of  mucous 
rales,  involving  the  smaller  tubes.  Aside  from  the  bronchitis  and 
secondary  anemia,  the  examination  was  negative.  The  child  had 
attended  school  at  irregular  intervals,  but  only  for  a  few  weeks 
of  her  Hfe.  While  getting  the  history,  I  asked,  as  a  matter  of  routine, 
if  the  child  snored  or  if  she  were  a  mouth-breather.  This  caused 
the  mother  to  remark  that  the  child  had  been  under  the  care  of 
throat  specialists  at  different  times  and  each  of  them  had  removed 
a  set  of  tonsils  and  a  set  of  adenoids !  She  did  not  think  that  there 
was  very  much  left.  In  spite  of  a  normal  rhinopharynx,  the  colds 
had  continued.  There  was  not  a  sign  of  a  tonsil  and  the  nasopharynx 
was  free.  In  taking  the  family  history,  I  had  learned  that  it  was 
rheumatic  on  both  sides,  extending  back  for  two  or  three  generations. 
The  mother  claimed  to  have  suffered  a  great  deal  from  rheumatism. 
In  getting  the  personal  history,  I  asked  if  the  child  was  fond  of  red 
meat.  The  reply  was  that  she  lived  on  it,  and  cared  for  little  else, 
unless  it  was  sugar.  Here  was  a  girl  eight  years  of  age  who  would 
not  drink  milk  until  sugar  had  been  added  to  it.  Cereals,  stewed 
and  raw  fruits  were  loaded  down  with  sugar  before  she  would  touch 
them. 

In  my  instructions  as  to  the  treatment,  red  meat  was  allowed 
30 


466  INFECTIOUS   FEVERS 

once  every  second  day  and  sugar  was  reduced  to  a  minimum — pro- 
bably not  rnore  than  one-fifth  the  usual  amount  being  given.  She 
was  to  be  bribed,  if  necessary,  to  eat  green  vegetables,  cereals,  and 
fruits.  Expectorant  and  cough  mixtures  were  discontinued.  She 
was  given  twenty  grains  of  the  bicarbonate  of  soda  and  twenty 
grains  of  the  salicylate  of  soda  daily  for  three  weeks.  Later,  the 
drug  treatment  was  continued  at  intervals  during  the  remainder 
of  the  winter.  She  passed  through  the  following  winter  without 
a  sign  of  rhinitis,  bronchitis,  or  asthma,  although  she  continued  to 
live  in  Brooklyn. 

Another  case  somewhat  similar  was  sent  to  me  by  a  well-known 
rhinologist.  The  girl,  seven  years  old,  had  suffered  from  repeated 
attacks  of  bronchitis  and  asthma.  She  had  been  confined  to  her 
home  a  greater  part  of  each  winter.  Her  general  condition  was 
thoroughly  wretched.  Her  family  physician  attributed  the  con- 
dition to  enlarged  tonsils  and  adenoids.  The  child  was  sent  to 
New  York  for  operation.  The  operation  was  performed  and  the 
child  returned  to  her  home.  As  a  result  the  patient  could  breathe 
easier  and  sleep  better,  and  suffered  much  less  during  her  attacks 
of  asthmatic  bronchitis;  but  the  frequency  of  the  attacks  was  in 
no  wav  affected.  Early  the  following  summer,  they  returned  to 
the  rhinologist,  who,  finding  the  condition  of  the  upper  respiratory 
tract  satisfactory,  asked  me  to  take  charge  of  the  case,  remarking 
that  he  had  "cut  everything  in  sight  and  out  of  sight" !  The  child, 
as  did  the  other  referred  to,  proved  to  be  an  excessive  meat  and 
sugar  eater,  and,  moreover,  the  mother's  family  was  rheumatic. 
The  treatment  outlined  above  was  instituted ;  and,  while  the  results 
were  not  so  flattering,  the  condition  was  much  improved;  only 
three  attacks  occurred  during  the  next  twelve  months,  and  the  child 
gained  fifteen  pounds  in  weight. 

Repeated  inflammatory  involvement  of  the  mucous  membrane 
of  the  upper  respiratory  tract  in  children,  in  the  absence  of  enlarged 
tonsils  and  adenoids,  suggests  strongly  a  rheumatic  element  as  a 
prominent  causative  factor.  Rheumatic  pleurisy  requires  the 
same  treatment  as  rheumatism.  In  my  four  cases  referred  to  above 
there  was  a  rheumatic  history  in  two.  The  children  were  between 
two  and  six  years  of  age.  There  was  no  pneumonia,  no  lung  in- 
volvement of  any  nature.  Aspiration  showed  clear  fluid,  which, 
upon  examination,  proved  sterile.  The  children  were  given  an 
anti-rheumatic  diet  with  the  salicylate  and  the  bicarbonate  of  soda 
in  doses  suitable  for  their  ages,  with  the  result  that  in  all  there  was 
a  complete  absorption  of  the  fluid  in  less  than  one  w^eek.  The 
treatment  of  rheumatic  endocarditis  will  be  found  elsewhere  (page 
291). 

Treatment. — Diet.  —  Acute  articular  rheumatism  or  rheumatic 
fever  is  rarely  seen  in  children  under  three  years  of  age.     It  is  usually 


RHEUMATISM  467 

the  larger  joints  that  are  involved — the  shoulder,  the  elbow,  the  knee, 
or  the  ankle.  The  lesion  may  be  single  or  multiple.  Rest  in  bed  is 
an  absolute  necessity.  The  diet  of  the  patient  may  consist  of  milk, 
junket,  gruel,  toast,  stale  bread,  weak  tea,  stewed  fruit,  and  orange- 
juice,  Vichy  and  lemonade  may  be  given  to  drink.  There  should 
be  one  evacuation  of  the  bowels  daily. 

Local  Measures. — Considerable  comfort  may  be  furnished  by 
local  measures,  which  will  permit  the  child  to  sleep,  resulting  in 
a  much  improved  food  capacity.  The  affected  joint  or  joints 
should  be  comfortably  supported  on  a  cushion  or  pillow,  and 
the  parts  kept  well  protected  by  cotton-wool  or  flannel  dressings. 
The  U.  S.  P.  lead  and  opium  solution  which  is  used  to  moisten  the 
gauze  dressings  will  aid  in  relieving  the  pain.  The  joint  is  loosely 
wrapped  in  strips  of  linen  which  have  been  wet  with  the  warm 
solution.  Over  this  is  placed  oiled  silk  to  prevent  rapid  evaporation 
and  over  all  a  flannel  bandage  is  wrapped.  In  the  acute  cases  the 
dressing  should  be  changed  every  hour  until  the  pain  is  relieved. 
This  can  readily  be  done  without  disturbing  the  patient.  A  liniment 
composed  of  menthol,  two  drams,  tincture  of  opium,  one  and  one- 
half  ounces,  and  enough  alcohol  to  make  six  ounces,  applied  on 
strips  of  linen  and  covered  with  oiled  silk,  is  another  form  of  local 
treatment  which  has  been  of  considerable  service  in  relieving  pain. 
The  dressing  should  be  renewed  every  two  or  three  hours  if  the 
case  requires  it. 

Drugs. — \^arious  drugs,  such  as  oil  of  wintergreen,  aspirin,  and 
combinations  of  the  alkalies  with  the  salicylates,  have  been  used 
in  a  considerable  number  of  cases.  The  most  effective  internal 
medication  has  been  the  bicarbonate  in  association  with  the  sali- 
cylate of  soda.  The  salicylate  must  be  given  in  large  doses.  Two 
points,  however,  are  to  be  kept  in  mind  in  the  use  of  large  doses 
of  salicylate  in  children:  Their  depressing  effect  upon  the  heart, 
and  their  tendency  to  produce  derangement  of  digestion,  as  evi- 
denced by  nausea  and  vomiting.  The  salicylate  should  never  be 
given  with  the  stomach  empty.  It  is  given  to  the  best  advantage 
after  meals,  and  always  in  solution.  For  a  child  five  years  of  age, 
the  following  may  be  prescribed : 

I^.     Sodii  salicylatis 5ij 

Elixiris  simplicis glss 

Aquae q.  s.  ad  giv 

Sig. — One  teaspoonful  four  times  daily  after  meals,  in  plain  water 
or  in  Vichy. 

There  are  about  twenty-four  teaspoonfuls  in  a  four-ounce  bottle. 
The  average  teaspoonful,  as  is  well  known,  holds  more  than  one 
dram.  Computing  twenty-four  doses  to  a  four-ounce  mixture,  we 
give  this  five-year-old  patient  twenty  grains  of  salicylate  of  soda 
in  twenty-four    hours.     The    amount    may  be  increased  to  thirty 


468  INFECTIOUS   FEVERS 

grains  if  the  condition  is  serious.  Larger  doses  than  thirty  grains 
to  children  of  this  age  I  do  not  consider  safe,  as  I  have  seen  such 
doses  followed  by  irregularity  of  the  heart's  action  and  cyanosis. 
The  average  child  from  eight  to  ten  years  of  age  will  take  thirty 
grains  daily  without  inconvenience.  From  the  second  to  the  third 
year,  I  have  given  from  twelve  to  fifteen  grains  repeatedly,  with 
most  satisfactory  results.  The  bicarbonate  of  soda  may  be  given 
in  combination  with  the  salicylate,  but  it  is  best  given  alone  in 
Vichy  or  carbonic  water  between  meals.  For  a  child  five  years 
old  or  under,  twenty  grains  should  be  given  in  twenty-four  hours. 
In  children  from  seven  to  ten  years  of  age,  thirty  to  forty  grains 
daily  is  the  amount  required.  During  an  attack  of  rheumatic 
fever,  the  patient's  heart  should  be  examined  daily.  The  dosage 
both  of  the  salicylate  and  the  bicarbonate  of  soda  should  gradu- 
ally be  reduced,  as  the  condition  of  the  child  improves. 

It  is  my  custom  never,  willingly,  to  let  a  child  who  has  once  had 
an  attack  of  acute  articular  rheumatism  disappear  from  my  observa- 
tion. With  repeated  attacks,  endocarditis  is  liable  to  develop  sooner 
or  later.  After  one  attack,  the  parents  are  advised  as  to  the  proba- 
bility of  a  recurrence,  and  its  dangers  are  pointed  out  to  them.  They 
are  instructed  to  keep  the  child  on  a  low  meat-and-sugar  diet-^red 
meat  never  being  allowed  oftener  than  once  every  second  day,  while 
sugar  is  given  only  in  sufhcient  quantity  to  make  the  food  palatable. 
Five  days  out  of  every  fifteen,  ten  grains  of  the  salicylate  of  soda, 
separately  or  combined  with  ten  grains  of  the  bicarbonate,  are  given 
daily.  This  should  be  continued  for  six  months,  when  the  five- 
day  treatment  out  of  each  month  will  suffice.  In  some  cases  I 
have  continued  this  method  indefinitely. 

At  the  present  time  a  boy  eleven  years  old,  who  has  had  two 
attacks  of  rheumatic  endocarditis,  is  taking  ten  grains  of  each  of  the 
above  drugs  daily  for  one  week  out  of  each  month,  and  has  been 
doing  so  for  two  years.  He  comes  of  a  long  line  of  rheumatic  an- 
cestry, and  so  prominent  is  the  rheumatic  element  in  him,  that  he 
frequently  has  attacks  of  angina  and  muscle  pain  in  spite  of  the  diet 
and  the  above  prophylactic  treatment. 

PELIOSIS  RHEUMATICA 
In  this  unusual  affection,  which  appears  to  be  of  rheumatic 
origin,  purpura  is  a  prominent  symptom.  In  my  patients  the  pur- 
puric area  has  always  been  over  the  anterior  portion  of  the  lower 
extremities.  ]\Iy  cases,  five  in  number,  have  all  occurred  in  those 
who  had  had  previous  attacks  of  rheumatism  or  chorea,  or  in  those 
in  whom  the  rheumatic  clement  was  prominent,  as  shown  by  re- 
current tonsillitis  or  recurrent  bronchitis.  A  further  proof  of  the 
rheumatic  origin  of  the  disease  is  the  fact  that  the  cases  usually 
yield  readily  to  treatment  for  rheumatism. 


TUIJIiRCULOUS    PERITONITIS  469 

In  one  of  my  patients  there  were  two  distinct  attacks,  both  of 
which  yielded  fairly  well  to  the  salicylate  of  soda  and  the  iodid  of 
potash.  The  medication  and  diet  are  the  same  as  that  suggested 
for  rheumatism.  In  case  erythema  nodosum  is  present  at  the  same 
time,  local  measures  for  the  relief  of  pain  (page  409)  will  be  neces- 
sary. 

ACUTE  GENERAL  PERITONITIS 

This  disease  is  not  an  infrequent  one  in  young  children.  I 
have  seen  four  cases  during  the  past  year.  Two  were  associated 
with  scarlet  fever  and  two  with  enterocolitis.  Perforation  of  the 
intestine  and  trauma  may  cause  peritonitis,  as  in  the  adult.  The 
most  frequent  cause,  however,  is  the  invasion  of  the  peritoneum 
by  pathogenic  bacteria.  The  peritoneum  in  young  children  appears 
to  be  particularly  susceptible  to  various  forms  of  infection.  Three 
symptoms  were  present  in  my  cases — persistent  vomiting,  abdominal 
distention,  and  constipation.  Pain  was  absent  in  one  case  and 
not  marked  in  some  of  the  others.  The  pulse  in  all  was  small  and 
rapid.  The  constipation  was  as  obstinate  as  though  actual  ob- 
struction existed. 

The  medical  treatment  in  my  experience  has  been  without  value. 
Every  case  has  resulted  fatally.  In  the  majority,  surgeons  were 
called  in  consultation,  but  invariably  advised  against  operative  pro- 
cedures. 

Never  having  had  a  case  recover,  I  am  not  in  a  position  to  advise 
treatment. 

TUBERCULOUS  PERITONITIS 

In  tuberculous  involvement  of  the  peritoneum  the  disease  is 
usually  well  advanced  by  the  time  it  comes  into  the  hands  of  the 
pediatrist.  The  chief  question  that  concerns  us  at  the  present  time 
is  as  to  the  advisabiUty  of  the  operation  of  laparotomy. 

When  to  Operate. — My  course  is  as  follows:  If  there  is  marked 
ascites  with  much  discomfort,  operation  is  advised  at  once.  It 
would  seem  that  early  operation  furnishes  the  best  chance  for  re- 
covery in  the  actively  acute  cases.  When  there  is  evidence  of  in- 
terference with  normal  peristalsis,  as  indicated  bv  persistent  consti- 
pation and  visible  peristalsis,  it  means  that  intestinal  obstruction  is 
imminent,  and  immediate  laparotomy  is  advised.  When  the  above 
conditions  do  not  obtain,  I  have  found  it  advisable  to  postpone  ope- 
ration and  attempt  to  relieve  the  patient  by  hygienic  measures,  diet, 
and  medication. 

Some  of  the  cases  seen  by  me  were  absolutely  hopeless  at  the 
time,  showing  marked  tuberculous  processes  elsewhere,  and  there- 
fore were  not  considered  fit  subjects  for  operation.  In  the  non- 
surgical treatment  of  these  cases  the  chief  points  of  importance 
to  be  considered  are  nutrition,  fresh  air,  and  a  thorough  daily  bowel 
evacuation. 


470  INFECTIOUS   FEVERS 

As  long  as  there  is  a  temperature  above  ioo°  F.  or  abdominal 
pain,  the  patient  should  be  kept  in  a  recumbent  position  and  out 
of  doors.  Moderate  exercise  is  to  be  encouraged  as  soon  as  the 
conditions  allow.  The  same  methods  of  constitutional  treatment 
as  to  diet  and  cHmate  are  to  be  followed  out  as  are  laid  down  in  the 
treatment  of  Pulmonary  Tuberculosis  (page  285).  The  patient 
should  be  weighed  once  a  week,  and  in  case  of  a  continuous  loss 
in  weight  and  strength  extending  over  five  or  six  weeks,  with  or 
without  fever,  in  spite  of  the  advantage  of  diet  and  climate,  oper- 
ation is  advised,  regardless  of  the  stage  of  the  process,  provided 
always  there  is  no  active  tuberculous  process  elsewhere.  When 
the  weight  remains  stationary  or  nearly  so  for  two  or  three  months, 
laparotomv  is  advised.  In  the  event  of  improvement  and  gain 
in  w^eight,  the  expectant  treatment  is  continued. 

Illustrative  Case. — The  necessity  for  operation  cannot  always  be 
convincingly  impressed  upon  the  parents.  A  few  years  ago  the  con- 
dition of  a  private  case,  a  boy  three  years  of  age,  was  persistently 
bad.  There  was  moderate  fever,  emaciation  to  a  marked  degree, 
with  later,  tubercular  involvement  of  two  of  the  dorsal  vertebrae. 
Laparotomy  was  suggested  early  in  the  illness,  but  it  was  refused, 
and  the  child  after  a  prolonged  illness  made  a  complete  recovery 
both  from  the  tuberculous  peritonitis  and  the  tuberculous  caries 
of  the  vertebrae.  In  this  case  I  am  convinced  that  an  unnecessary 
risk  was  taken,  and  that  recovery  from  the  peritonitis  would  have 
been  much  more  rapid  and  the  vertebral  involvement  probably 
prevented  by  an  early  laparotomy. 

DACTYLITIS 

Dactylitis  consists  of  a  fusiform  sweUing  on  one  or  more  of  the 
phalanges  of  the  fingers.  It  may  be  of  two  forms,  dactylitis  syphi- 
litica and  dactylitis  tubercidosa.  The  differentiation  between  the 
two  conditions  is  oftentimes  most  difficult.  In  the  syphiUtic  type 
the  lesions  are  more  apt  to  be  multiple  and  are  associated  with 
syphilitic  lesions  elsewhere.  Furthermore,  these  cases  are  favorably 
influenced  by  anti-syphiHtic  treatment,  which  is  not  the  case  with 
the  tuberculous  form. 

Aside  from  the  anti-syphilitic  treatment,  the  management  of 
the  two  forms  is  the  same.  Absolute  rest  to  the  parts  appears  to 
be  essential  for  successful  treatment.  This  is  best  secured  by  the 
use  of  splints,  which  must  be  kept  bound  on  the  fingers  for  months 
in  such  a  way  as  effectually  to  immobilize  them.  In  a  recent  case 
of  the  tuberculous  form,  successfully  treated  in  this  way,  the  fin- 
ger was  kept  in  splints  for  six  months.  When  abscess  and  necrosis 
occur,  the  case  must  be  treated  along  surgical  lines,  the  immobility 
of  the  parts  being  maintained  as  completely  as  the  conditions  allow. 


GLANDULAR   FEVER  47^ 


TUBERCULOUS  BONE  DISEASE 

Children  afllictc-d  with  tuberculous  bone  disease,  whether  in  the 
spine,  the  hip-joint,  the  knee-joint,  or  elsewhere,  'should  be  in  the 
hands  of  the  general  or  orthopedic  surgeon.  The  constitutional 
treatment  of  these  cases,  however,  is  most  important,  and  is  largely 
along  nutritional  and  hygienic  lines,  for  the  better  the  nutrition 
and  the  physical  condition  of  the  patient,  the  more  complete  and 
prompt  will  be  the  results  of  the  surgeon's  efforts. 

Diet. — A  tuberculous  child  should  receive  a  generous  amount  of 
fat  and  nitrogenous  food.  There  should  be  no  forced  feeding,  as  this 
almost  invariably  makes  the  child  ill,  or  he  will  become  disgusted  with 
all  food.  What  is  required  is  a  liberal  supply  of  properly  selected, 
properly  prepared  food.  The  diet  advocated  in  the  Tardy  Malnu- 
trition cases  and  in  Pulmonary  Tuberculosis  should  be  employed 
here.  The  five  meals  a  day  which  are  often  advocated  for  tuberculous 
children,  I  have  been  unable  to  give  with  advantage.  The  most  fre- 
quent feedings  that  I  have  been  able  to  give  with  benefit  for  children 
of  three  years  or  over  are  the  three  daily  meals,  with  a  glass  of  milk 
or  cocoa  in  the  middle  of  the  afternoon.  As  much  outdoor  hfe 
as  is  possible  should  be  afforded  the  patient.  City  children  always 
improve  more  rapidly  when  placed  in  good  surroundings  in  the 
country. 

GLANDULAR  FEVER 

Glandular  fever  is  usually  seen  in  children  after  the  first  year. 
The  disease  is  due  to  a  local  infection  the  nature  of  which  is  unknown. 
The  lymph-nodes  at  the  angle  of  the  jaw  are  involved,  forming 
an  elongated  tumor  between  the  angle  of  the  jaw  and  the  sterno- 
mastoid  which  may  reach  a  considerable  size.  I  have  seen  cases 
during  the  past  winter  in  which  the  tumors  were  as  large  as  hens' 
eggs.  Both  sides  are  usually  involved;  the  swelling  is  first  noticed 
on  one  side,  which  is  often  followed  by  an  enlargement  of  the  glands 
on  the  opposite  side. 

The  symptoms  are  fever,  usually  from  ioi°  to  104°  F.,  prostra- 
tion, and  loss  of  appetite.  The  disease  is  to  be  differentiated  from 
mumps  in  that  the  parotid  glands  are  not  involved,  and  from  acute 
simple  adenitis  by  the  absence  of  throat  involvement.  In  several  of 
the  cases  seen  during  the  past  winter  and  spring  (igo6),  the  rhino- 
pharynx  was  normal. 

The  treatment  consists  in  the  continuous  use  of  ice-bags  and 
laxatives,  such  as  milk  of  magnesia  or  citrate  of  magnesia,  sufficient 
to  produce  one  or  two  evacuations  daily,  a  reduced  diet  of  broths 
and  gruels,  and  keeping  the  patient  in  bed.  The  swelling  may  last 
from  five  days  to  two  weeks,  and  in  my  cases  has  subsided  without 
suppuration. 


472  INFECTIOUS   FEVERS 


CYCLIC  VOMITING 

Recurrent  attacks  of  persistent  vomiting  are  frequently  seen 
by  the  pediatrist.  An  attack  comes  on  suddenly  with  little  or 
no  warning.  At  first  the  contents  of  the  stomach  are  vomited; 
later,  in  many  cases,  whatever  may  be  taken  in  the  line  of  food  or 
drink.  When  no  food  is  taken,  the  dry  retching  and  vomiting  of 
mucus  continue,  the  latter  for  a  few  hours,  for  an  entire  day,  or 
for  several  days.  The  most  prolonged  case  under  my  observation 
was  in  a  boy  three  years  of  age,  who  vomited  persistently  for  thir- 
teen days.  The  cessation  of  the  vomiting  is  usually  as  abrupt  as 
its  onset,  the  patient  asking  for  and  retaining  the  nourishment 
which  is  given  him.  If  the  attack  is  a  short  one  and  mild  in  char- 
acter, the  customary  diet  will  usually  be  taken  at  once  thereafter 
without  inconvenience.  If  the  attack  has  been  prolonged,  with 
much  straining  and  vomiting  of  mucus  streaked  with  blood,  or 
if  there  has  been  a  decided  hematemesis,  which  I  have  seen  in  some 
cases,  the  resumption  of  the  feeding  will  necessitate  considerable 
care.  In  such  cases  broths,  kumyss,  and  bland  non-irritating  articles 
of  diet  generally  will  have  to  be  given. 

Treatment. — According  to  my  observation  direct  medication  to  the 
stomach  during  the  attack  is  valueless.  Our  efforts  are  best  exerted 
in  maintaining  the  nutrition  of  the  patient.  All  attempts  at  supply- 
ing water  or  food  by  the  stomach  should  be  discontinued.  Nutrient 
enemata  and  colon  flushings  are  invaluable  in  all  of  the  prolonged 
cases — those  lasting  over  forty-eight  hours.  In  addition  to  the 
discomfort  produced  by  the  vomiting,  these  patients  suffer  greatly 
from  thirst.  The  necessary  amount  of  fluid  can  be  supplied  by  colon 
flushings.  For  a  child  five  years  of  age  one  pint  of  normal  salt  solution 
may  be  introduced  into  the  colon  through  an  ordinary  rectal  tube 
(page  208).  I  have  often  known  patients  to  retain  as  much  as 
two  pints  of  fluid  a  day  when  it  was  thus  given.  If  the  case  promises 
to  last  more  than  three  days,  it  is  best  to  begin  with  nutrient  enemata 
on  the  third  or  fourth  day.  For  this  purpose  I  employ  from  six 
to  eight  ounces  of  completely  peptonized  skimmed  milk,  to  which 
the  whites  of  two  eggs  have  been  added.  This  is  given  at  eight- 
hour  intervals.  The  use  of  the  salt  solution  and  peptonized  milk 
furnishes  sufficient  fluid  nutriment  to  sustain  the  child  until  the 
vomiting  ceases.  In  two  cases  only  have  I  been  obliged  to  resort 
to  morphin  hvpodermatically,  to  control  the  frequency  and  violence 
of  the  vomiting  attacks. 

All  of  my  cases  of  cyclic  vomiting — and  I  have  treated  over 
thirty  of  them — have  been  without  exception  in  children  of  rheu- 
matic inheritance  or  in  those  in  whom  rheumatism  was  evident 
by  some  unmistakable  sign.  It  is  therefore  of  great  advantage 
to  consider  these  cases  and  treat  them  as  though  thev  were  of  rheu- 


CYCLIC    VOMITING  473 

matic  origin.  The  attacks  perhaps  may  not  be  entirely  prevented, 
but  in  practically  every  case  they  may  be  delayed  by  putting  the 
patient  upon  suitable  treatment  in  the  intervals.  My  custom  is 
to  give  only  a  hmited  amount  of  animal  proteid  and  a  diet  scanty 
in  sugar  or  with  sugar  entirely  excluded  if  the  case  is  a  severe  one. 
The  use  of  green  vegetables,  fruits,  and  cereals  is  encouraged. 

To  a  child  of  from  three  to  ten  years  of  age,  from  nine  to  twelve 
grains  of  salicylate  of  soda  or  aspirin  are  given  after  meals  daily 
in  divided  doses,  for  five  days  out  of  every  fifteen.  During  the 
ten  days  of  rest  from  the  salicylate,  five  grains  of  bicarbonate  of 
soda  are  given  twice  daily  between  meals.  This  scheme  of  treatment 
is  continued  for  months.  If  the  salicylate  of  soda  interferes  with 
digestion  or  with  the  appetite,  aspirin  in  equal  dosage  is  substituted. 
By  following  this  method  of  treatment  in  cases  where  attacks  had 
been  occurring  every  month  or  six  weeks,  the  intervals  between  them 
have  been  increased  to  six  months  or  a  year,  and  in  several  instances 
the  attacks  have  entirely  ceased.  Spasmodic  treatment  of  these  cases 
is  of  little  value;  only  persistent  treatment  is  effective,  and  there 
must  be  confidence  and  cooperation  on  the  part  of  the  family  or 
anv  treatment  will  fail. 


TEMPERATURE  IN  CHILDREN 

Normal  Temperature. — The  question  is  often  asked:  What  is 
the  normal  temperature  of  a  baby  or  young  child  of  a  given  age? 
In  order  to  answer  this  question  from  our  own  observation,  a  study 
of  the  matter  was  carried  out  at  my  suggestion  by  Dr.  H.  G.  Myers, 
resident  physician  at  The  New  York  Infant  Asylum.  This  study 
comprises  fifty-nine  cases,  the  ages  varying  from  birth  to  one  year. 
Only  well  children  were  selected  for  the  observation,  the  majority 
being  breast-fed.  The  temperatures  in  each  instance  were  taken 
by  the  rectum  for  four  minutes. 

It  was  found  in  these  infants  that  the  birth  temperature  ranged 
from  96°  to  98°  F.,  exceeding  98°  F.  in  but  five  cases,  when  it  was 
between  98°  and  99°  F.  In  one  it  was  94°  F.  During  the  twenty- 
four  hours  following  birth  there  was  a  rise  in  the  temperature  usually 
of  about  one  degree.  From  this  time  on,  there  was  little  varia- 
tion in  the  temperature,  when  the  child  was  well,  regardless  of  the 
age.  There  would  be  a  variation  at  different  times  of  the  day  of 
a  fraction  of  a  degree,  it  being  higher  in  the  evening.  Upon  looking 
over  the  charts  upon  which  the  results  were  chronicled,  one  is  im- 
pressed by  the  uniformity  of  the  temperature,  ranging,  as  it  does, 
within  fairly  narrow  limits,  from  98°  to  99.2°  F. 

Instances  when  the  temperature  arose  to  99.5°  F.  were  occasionally 
seen,  but  100°  F.  was  very  unusual.  It  is  not  claimed  that  the  tempera- 
ture of  a  well  child  may  not  reach  100°  F. ;  in  fact,  there  were  occa- 
sions when  it  rose  to  101°  F.  and  illness  could  not  be  proved,  arid 
had  not  the  temperature  been  taken  for  the  purpose  above  men- 
tioned, no  elevation  would  have  been  suspected,  for  when  next  taken 
the  temperature  was  normal.  In  those  cases  in  which  a  rise  was 
proved  to  be  an  early  sign  of  illness,  the  recording  of  the  tempera- 
ture was  discontinued  and  the  first  reading  was  not  included  in  the 
observations.  In  one  child  a  temperature  of  103°  F.  was  found.  It 
remained  at  this  point  for  three  hours,  when  it  fell  to  normal  with- 
out any  other  manifestation  of  trouble.  When,  however,  the  ther- 
mometer registered  over  99.5°  F.,  some  cause  for  the  elevation  could 
usually  be  discovered;  though  it  may  have  been  nothing  more 
than  excitement  or  a  slight  indigestion. 

Several  years  ago  I  personally  made  a  similar  series  of  observa- 
tions at  the  Country  Branch  of  The  New  York  Infant  Asylum  in 
twenty-five  healthy  children  under  eighteen  months  of  age.  The 
temperatures  were  taken  four  times  a  day,  the  observations  extending 
over  an  entire  week.     It  was  found  in  these  well  children  that  the 

474 


TEMPERATURE   IN   CHILDREN  475 

temperature  varied  from  98°  to  99°  F. ;  when  it  rose  every  day  above 
99.5°  F.,  some  abnormal  condition  was  always  found  to  explain  it. 

Judging  from  these  observations  in  seventy-four  well  children, 
ranging  in  age  from  birth  to  eighteen  months,  whose  temperatures 
were  taken  several  hundred  times,  it  would  seem  that  a  daily  rise 
above  99.5°,  F.  may  be  considered  abnormal.  An  occasional  rise, 
however,  considerably  higher  than  this,  as  above  mentioned,  may 
occur  and  does  occur  in  perfectly  healthy  children,  without  being 
of  any  special  significance. 

Fever.— By  fever,  then,  in  infants  and  children  we  understand  an 
increase  above  that  which  is  considered  the  normal  body-temperature. 

In  children,  for  cHnical  purposes,  the  rectal  temperature  should 
always  be  taken.  For  those  under  five  years  of  age  the  mouth  is 
unsafe,  because  the  child  is  apt  to  bite  off  the  thermometer  bulb, 
and  unrehable,  because  the  lips  will  not  remain  closed  the  requisite 
three  or  four  minutes.  The  axillary  temperature  is  thoroughly 
misleading  and  should  never  be  depended  upon.  Thermometers 
should  be  carefully  disinfected  with  alcohol  after  using.  One- 
minute  thermometers,  according  to  my  observations,  are  often 
unrehable  and  should  not  be  used. 

The  highest  temperature  personally  known  to  the  writer  was 
111°  F.  This  was  as  high  as  the  thermometer  could  register.  It 
occurred  in  a  child  of  ten  months  who  was  in  a  convulsion,  which 
was  one  of  the  first  symptoms  of  a  tuberculous  meningitis.  The 
child  had  been  placed  by  the  parents  in  water  at  a  temperature  of 
115°  F.  It  had  been  in  the  water  about  ten  minutes  before  the 
rectal  temperature  was  taken.  How  much  the  temperature  was  due 
to  the  illness  and  how  much  to  the  hot  water  will  never  be  known. 
The  temperature  responded  promptly  to  a  cold  bath.  The  child  never 
regained  consciousness  and  died  of  meningitis  ten  days  after  the 
initial  convulsion. 

Fever  may  or  may  not  be  an  index  of  the  gravity  of  a  disease; 
thus  we  frequently  have  a  temperature  ranging  from  103°  to  105° 
F.  in  tonsillitis,  acute  indigestion,  and  stomatitis — ailments  w^hich 
respond  very  quickly  to  treatment  and  which  present  no  serious 
aspects.  In  typhoid  fever,  pneumonia,  scarlet  fever,  and  diph- 
theria, however,  when  the  temperature  range  is  above  104°  F.,  it 
is  a  symptom  of  considerable  value,  as  indicating  the  severity  of 
the  infection;  so  that  it  is  not  the  fever  itself,  but  the  condition 
back  of  and  associated  with  it,  which  makes  it  a  sign  of  clinical 
value.  In  pneumonia,  children  bear  a  comparatively  high  tem- 
perature, 104°  F.,  for  example,  without  much  discomfort  or  danger; 
while  in  the  acute  intestinal  disorders  of  summer,  an  equal  degree 
of  fever  is  borne  very  badly,  and  if  continued  is  of  grave  signifi- 
cance.    This  must  be  kept  in  mind  in  our  dealings  with  fever. 

When  is  a  given  temperature  to  be  interfered  with?  is  a  ques- 


476  TEMPERATURE   IN    CHILDREN 

tion  which  concerns  all  practitioners.  This  depends  to  a  great 
extent  upon  the  cause  of  the  fever  and  its  effects  upon  the  patient. 
If  the  fever  produces  diminished  assimilation,  loss  of  sleep,  irri- 
tabiUty,  and  restlessness,  it  will  do  the  child  harm  by  diminishing 
the  normal  resistance  to  disease,  and  should  be  relieved  whether 
it  is  102°  F.  or  105°  F.,  so  that  interference  is  dependent  not  so  much 
upon  the  height  of  the  temperature  as  upon  its  effects  upon  the 
patient. 

The  methods  of  reUeving  fever  are:  (i)  Elimination:  This  ap- 
plies particularly  to  the  gastro-enteric  tract  and  the  skin.  In  a 
majority  of  the  cases  of  high  fever  due  to  an  acute  indigestion  with 
resulting  toxemia,  a  purgation,  a  bowel-washing,  and  a  carefully 
adjusted  diet  for  a  day  or  two,  and  the  case  is  well.  We  remove 
the  cause  of  a  fever,  and  the  fever  subsides.  Unfortunately,  this 
means  of  controlling  fever  is  limited  to  the  gastro-enteric  tract. 
(2)  Diaphoresis,  by  which  is  understood  the  production  of  an  exces- 
sive perspiration,  will  also  relieve  high  temperature.  The  most 
reliable  way  of  bringing  this  about  in  a  child  is  by  the  use  of  mod- 
erately heavy  covering  and  the  administration  of  the  tincture  of 
aconite,  in  doses  of  one-half  to  one  drop  every  hour, — eight  doses 
in  twenty-four  hours;  or  Hquor  ammonii  acetatis,  two  drams  every 
two  hours,  for  a  child  one  year  old.  (3)  By  far  the  most  satisfactory 
means  of  controlling  fever  depends  upon  the  local  abstraction  of 
heat  by  means  of  sponging  (page  480),  tub-baths  (page  30),  and 
cool  packs  (page  481).  (4)  Antipyretic  drugs:  Much  which  borders 
on  the  sensational  has  been  written  about  the  harmfulness  of  an- 
tipyretic drugs,  particularly  the  coal-tar  products.  Used  in 
large  and  frequent  doses,  they  certainly  may  do  a  great  deal  of 
damage;  under  certain  conditions,  used  in  small  doses  and  repeated 
at  intervals  of  from  three  to  six  hours,  they  may  be  and  often  are 
of  benefit.  Aconite  and  the  liquor  ammonii  acetatis  are  of  some 
value,  as  above  stated,  but  they  are  of  little  value  in  controlling 
a  very  high  persistent  temperature.  The  coal-tar  products  furnish 
the  best  antipyretic  drugs  and  may  be  used  with  safet}^  but  should 
be  used  only  when,  for  any  reason,  the  local  abstraction  of  heat 
by  the  application  of  cold  is  impossible.  In  many  families  there  is 
too  Httle  intelligence  to  make  a  cold  pack  either  possible  or  safe. 
In  severe  cases  of  pneumonia  and  scarlet  fever,  and  in  the  intestinal 
diseases,  sponging  often  will  not  answer.  Only  a  trained  nurse 
or  a  very  intelligent  mother  should  be  entrusted  with  a  pack.  More- 
over, sponging  and  tub-bathing,  if  repeated  too  frequently,  particu- 
larly during  the  night,  exhaust  the  child.  Spongings  or  tub-baths 
are  often  strenuously  objected  to  by  parents  as  well  as  by  the  patient, 
and  if  the  nurse  is  one  of  the  family,  her  sympathy  will  counter- 
balance her  judgment,  and  the  result  be  far  from  satisfactory. 
Under  such  conditions,  when  the  application  of  cold  to  the  skin 


OBSCURE  ELEVATIONS  OF  TEMPERATURE  477 

is  impossible,  a  combination  of  phenacetin  and  caffcin,  alone  or 
with  Dover's  powder,  has  proved  effective.  The  antipyretic  treat- 
ment of  scarlet  fever  is  the  same  as  that  of  pneumonia  or  typhoid 
fever. 

My  use  of  antipyretic  drugs  has  been  confined  almost  entirely 
to  the  ignorant  in  private  work,  and  to  dispensary  patients.  For  a 
child  of  one  year  or  under,  one  grain  of  phenacetin  with  one-fourth 
grain  of  citrate  of  caffein  may  be  given  and  repeated  at  three-hour 
intervals  if  the  temperature  requires  it.  For  a  child  two  years  of  age 
i^  grain  of  phenacetin  and  ^  grain  of  citrate  of  caffein  at  three-hour 
intervals;  three  years  and  over,  i^  to  2 J  grains  of  phenacetin  with  ^ 
to  I  grain  of  citrate  of  caffein,  at  intervals  of  from  three  to  six  hours. 
If  there  is  much  restlessness  and  irritability  which  is  not  thus  con- 
trolled, Dover's  powder  may  be  added — ^  grain  to  each  dose, 
for  a  child  of  from  three  to  six  months  of  age;  ^  grain  between 
six  and  twelve  months;  one  grain  after  the  age  of  two  years  is 
reached.  It  is  always  wise  to  caution  parents  as  to  the  use  of  Dover's 
powder  in  children.  They  should  be  told  that  if  the  child  beocmes 
"heavy,"  or  difficult  to  arouse,  the  powders  must  be  discontinued. 
That  phenacetin  and  citrate  of  caffein  cannot  be  given  in  solution  is 
unfortunate.  I^ike  all  insoluble  powders,  they  are  best  given  in 
some  mucilaginous  mixture,  such  as  barley-water  or  one  of  the 
cereal  jellies.  Fruit- juice  or  apple-sauce  usually  answers  well. 
Antipyrin,  for  the  reason  that  it  forms  a  tasteless  mixture  with 
water,  succeeds  better  with  some  intractable  children,  and  may  be 
used  in  the  same  doses  as  phenacetin;  although  as  an  antipyretic 
it  is  less  efficient. 

OBSCURE  ELEVATIONS  OF  TEMPERATURE 
Perhaps  the  most  annoying  cases  in  pediatric  work  are  those 
with  an  elevation  of  the  temperature  for  which  no  adequate  cause 
can  be  discovered.  In  the  section  on  Normal  Temperature  cer- 
tain possible  variations  are  given  which  I  regard  as  within  the 
limits  of  health.  When  these  boundaries  are  passed,  when  there 
is  a  temperature  range  between  99°  and  101°  or  102°  F.,  or  a  tem- 
perature persistently  at  100°  or  101°  F.  without  any  apparent  cause, 
and  continuing  for  days  and  weeks,  the  medical  adviser  is  not  in 
an  enviable  situation.  Such  cases  coming  to  the  pediatrist  through 
consultation  or  otherwise  are  sometimes  easy  of  solution.  At 
other  times,  however,  the  cause  of  the  fever  may  never  be  discovered, 
and  the  patient  eventually  gets  well,  leaving  us  still  in  ignorance  of 
the  cause  of  the  fever. 

Active  Exercise  in  Nervous  Children. — This  is  not  infrequently 
the  cause  of  an  elevation  of  the  temperature.  I  have  seen  several 
cases  of  this  nature.  A  few  years  ago  I  saw  in  consultation  a  country 
child  three  years  of  age,  whose  temperature  every  afternoon  at  one 


478  TEMPERATURE    IN    CHILDREN 

o'clock   was    1 02°   F.     The   child,    while   not   vigorous,    showed   no 
signs  of  illness.     He  ate  well,  slept  well,  and  played  hard.     There 
was  a  slow  gain  in  weight.     The  fever  was  discovered  by  the  mother, 
who  thought  that  the  child,  who  was  a  blonde,  looked  flushed  every 
day  at  about  the  same  time.      The  temperature  by  rectum  was  nor- 
mal in  the  morning  and  normal  at  night.     This  condition,  to  the 
attending  physician's  knowledge,  had  persisted  for  six  weeks  before 
I  saw  the  patient.     How  long  there  had  been  a  daily  elevation  of 
the  temperature  above  the  normal  before  the    mother  discovered 
it,  we  have  no  means  of  knowing.     The  doctor,  an  excellent  prac- 
titioner, had  suspected,  examined  the  child  for,    and  treated  him 
for  various  diseases;    the  first  being  malaria,  with   no  response  to 
quinin;    then  typhoid  fever,  as  by  suggestion  and  constant  inquiry 
the  child  came  to  imagine  that  he  must  be  sick,  and  complained 
of  languor.     The  fever  continued,  however,  beyond  the  usual  time 
allowance  for  typhoid  fever  and  there  were  no  other  symptoms. 
There  was  no  enlargement  of  the  spleen  and  the  blood  had  been 
repeatedly  found  negative  to  the  Widal  reaction.     Other  possible 
causes  of  the  fever  were  also  given  attention.     One  day  the  doctor 
suggested    tuberculosis.      This     aroused     the    family    and    friends 
and  a  consultation  was  the  immediate  result.      In  company  with 
the  doctor,  I  saw  the  child  at  its  home.     I   found  a  rather  thin 
blond   boy,  three  years   old.      The    family   history   was   excellent. 
There  was  one  other  child,  six  years  of  age,  who  was  well  and  a 
good  specimen  of  robust  boyhood.     The  patient  had  never  had  a 
pulmonary  disorder  and  no  disease  of  the  respiratory  tract  other 
than  slight  bronchitis.     There  was  no  apparent  association  of  the 
condition  with  any  intestinal  or  infectious  disease.     An  exhaustive 
physical  examination  failed  to  reveal  any  abnormaUty  other  than 
a  small  umbilical  hernia  and  a  slight  enlargement  of  the  inguinal 
and    submaxillary    glands.     The    blood    was    not    examined.     The 
child    was    pale    and    doubtless    a   blood    examination    would   have 
revealed  a  mild  secondary  anemia.     The  appetite  was  fairly  good; 
the  bowels  were  reported  regular  and  his  stools  normal.     The  child 
had  not  been  kept  in  bed,  as  the  family  did  not  consider  him  very 
ill.      The   physical  examination  being  negative,   I    questioned  the 
mother  very  closely  as  to  the  child's  habits  of  life.     I  found  that 
he  rose  at  7  a.  m.,  had  breakfast  at  7.30,  played  with  his  big  brother 
and  two  older  boys  until  one  o'clock,  when  he  had  dinner.     A  glass 
of  milk  and  a  piece  of  bread  and  butter  were  given  as  a  luncheon 
at  II  A.  M.     I  found  that  he  played  very  actively,  kept  up  with  the 
older  boys,  and  was  unhappy  when  he  was  not  with  them.     At- 
tempts had  been  made  without  success  to  entertain  him  with  less 
strenuous  play.     It  was  at  midday,  sometimes  before,  sometimes 
after  dinner,  that  the  temperature  reached  the  highest  point.     It 
seemed  to  me  that  here,  probably,  was  a  case  of  fatigue  temperature. 


OBSCURE  ELKVATIONS  OF  TEMPERATURE  479 

I  accordingly  suggested  that  the  boy  be  undressed  and  put  to  bed 
at  1 1. 1 5  A.  M.  after  the  Hght  luncheon  and  be  made  to  rest  and 
sleep  if  possible.  At  1.15  he  was  to  be  taken  up  for  dinner,  his 
temperature  first  being  taken.  These  instructions  were  faithfully 
carried  out,  and  I  am  pleased  to  state  that  this  ended  the  daily 
rise  in  temperature.  The  case  was  one  of  an  active,  nervous  child 
becoming  overtired  in  his  attempts  to  hold  his  own  with  older  and 
stronger  boys.  The  patient  improved  rapidly  in  his  physical  con- 
dition and  is  now,  after  an  interval  of  three  years,  perfectly  well. 

Another  child,  four  years  of  age,  was  seen  in  consultation  with 
a  New  York  physician,  because  of  a  daily  elevation  of  the  temper- 
ature to  from  100°  to  102.5°  F-.  which  had  continued  for  six  weeks. 
The  child  was  thriving  and  otherwise  perfectly  well.  No  cause 
of  the  fever  could  be  discovered  in  his  physical  condition.  He 
had  a  noisy,  excitable  nurse,  who  was  inclined  to  exciting  games 
and  rough  play  with  the  boy.  With  a  dismissal  of  the  nurse  the 
fever  ceased. 

Otitis. — Persistent  fever,  following  the  acute  catarrhal  affec- 
tions of  the  upper  respiratory  tract  and  the  exanthemata,  is 
sometimes  explained  by  a  suppurative  process  in  the  middle  ear, 
without  other  symptoms  than  the  fever. 

Encysted  Empyema. — A  small  area  of  encysted  empyema  may 
explain  a  persistent  fever,  following  pneumonia.  Holt  describes  a 
most  interesting  case  of  this  nature  in  which  there  was  for  over 
four  weeks  a  temperature  range  from  100°  to  105°  F.  Autopsy 
showed  a  small  collection  of  pus  between  the  diaphragm  and  the 
lung. 

Periodic  Fever. — Not  infrequently  we  see  cases  which  show 
some  of  the  clinical  signs  of  malaria  as  regards  periodicity  in  the 
temperature,  but  without  splenic  enlargement,  or  the  presence 
of  the  malarial  organism  in  the  blood.  Yet,  often,  these  cases  quickly 
respond  to  full  doses  of  the  bisulphate  of  quinin. 

Typhoid  Fever. — Occasionally  a  case  with  low  persistent  tem- 
perature elevation,  obscure  for  a  week  or  two,  proves  to  be  a  mild 
typhoid. 

Tuberculosis. — An  elevation  of  the  temperature  is  sometimes 
the  first  premonitory  symptom  of  tuberculosis.  Tuberculosis  in 
a  child,  however,  is  usually  an  active  process  when  it  involves  the 
lungs,  and  can  readily  be  made  out.  When  other  parts  are  involved, 
such  as  the  bones,  glands,  skin,  or  peritoneum,  the  manifestations 
are  usually  sufficiently  plain  to  indicate  the  condition. 

Intestinal  Infection. — Intestinal  infection  of  a  latent  type  may 
be  the  cause  of  persistent  fever.  In  a  suspected  case  in  the 
absence  of  bowel  symptoms,  it  is  well  to  give  a  laxative  and  put 
the  child  temporarily  on  a  reduced  diet  consisting  largely  of  carbo- 
hydrates. 


480  TEMPERATURE    IN    CHILDREN 

Unexplained  Elevations  of  Temperature. — I  have  known  children 
to  run  an  unexplained  temperature  of  from  100°  to  101.5°  F.  for 
weeks,  without  any  other  sign  of  illness.  I  have  had  these  cases 
examined  by  eminent  consultants  and  I  have  seen  them  recover 
without  a  diagnosis.  Of  one  thing,  however,  we  may  rest  assured: 
If  a  competent,  thorough  examination  of  the  patient  does  not  reveal 
the  cause  of  the  temperature,  we  are  safe  in  concluding  that  there 
is  nothing  of  a  very  serious  nature  back  of  it. 

Illustrative  Case. — The  history  of  a  case  of  this  kind,  which  gave 
me  no  end  of  trouble  and  annoyance,  may  not  be  without  interest. 

The  patient,  an  eight-year-old  boy,  was  the  only  son  of  a  habit- 
ually anxious  mother,  who  had  unfortunately  learned  to  use  the 
clinical  thermometer.  She  took  her  boy's  temperature  after  school 
one  day  early  in  December.  She  found  that  the  thermometer 
registered  100.5°  F.  I  was  consulted,  saw  the  boy  in  the  evening, 
took  his  temperature,  by  mouth,  with  my  own  thermometer,  and 
found  it  100.8°  F.,  with  no  other  evidence  of  disease.  He  was  per- 
fectly normal  in  every  other  respect.  He  maintained  that  he  felt 
well,  did .  not  need  a  doctor,  and  wished  to  be  let  alone  to  study 
his  lessons.  The  following  morning  the  temperature  was  100°  F. ; 
in  the  evening  it  was  nearly  101°  F.  For  six  weeks  this  temperature 
range  continued,  never  below  100°  F.,  never  higher  than  101.2°  F. 
The  boy,  against  my  advice,  was  taken  from  school.  He  was  put 
to  bed,  and  a  half-dozen  consultants  saw  him  without  shedding 
any  light  on  the  case.  Finally  the  mother  became  reconciled  to 
"doing  nothing  "  for  her  son,  and  he  was  taken  to  a  nearby  winter 
resort.  I  suggested  to  the  father  that  before  leaving  town  he  should 
"accidentally"  drop  the  thermometer  on  the  hardwood  floor  and 
then  refuse  to  have  another  in  the  house.  This  he  managed  to  do, 
straightway.  The  boy  had  an  excellent  time  at  the  winter  resort, 
played  with  his  sled  in  the  snow,  skated  on  the  lake,  fell  through 
the  ice  once  and  received  a  thorough  wetting,  without  harm.  In 
three  weeks  he  returned,  improved  as  much  as  any  city  child  improves 
from  a  country  outing.  His  temperature  was  not  taken  during  these 
three  weeks  at  the  winter  resort  and  has  not  been  taken  since,  except 
where  there  were  evidences  of  illness.  He  is  now  developing  along 
normal  lines  and  is  a  fair  physical  specimen  for  his  age. 

COLD  SPONGING  IN  FEVER 
Sponging  with  plain  water,  with  salt  water  (a  teaspoonful  of 
salt  to  a  pint  of  water),  or  with  alcohol  and  water  (one-fourth  alcohol 
to  three-fourths  water)  is  a  means  of  reducing  high  temperature 
with  which  every  physician  should  be  familiar.  Cool  sponging, 
75°  F.  to  80°  F.,  plain  or  medicated,  is  useful  for  two  purposes: 
as  a  sedative  and  for  the  reduction  of  fever.  In  measles  or  scarlet 
fever,  although  the  temperature  may  not  be  high,  the  itching  and 


THE   COOL   PACK  48 1 

burning  of  the  skin  prevent  sleep,  and  the  patient  is  very  uncom- 
fortable, but  often,  under  such  conditions,  he  will  fall  asleep  during 
a  careful  sponging.  In  pneumonia,  in  typhoid  fever,  and  in  the 
intestinal  disorders  of  summer,  my  nurses  have  a  standing  order 
to  give  a  cold  sponging  for  fifteen  minutes  at  any  time  when,  in  their 
judgment,  it  may  be  indicated,  not  on  account  of  the  fever  but 
because  of  its  sedative  effect  upon  the  patient.  A  sponging  of  from 
ten  to  fifteen  minutes  three  or  four  times  a  day  with  cool  water, 
65°  to  75°  F.,  will  greatly  help  a  baby,  whether  sick  or  well,  to  pass 
successfully  through  the  hot  days  of  summer. 

Sponging  for  fever,  while  possessing  less  antipyretic  value  than 
do  other  measures,  such  as  a  cold  pack,  for  example,  has  the  advan- 
tage in  that  it  is  safe  and  easy  of  application  in  the  hands  of  the 
most  unskilled,  and  will  be  of  assistance  in  controlling  high  tem- 
perature when  other  means  are  not  available.  In  order  not  to  antag- 
onize or  frighten  timid  children,  it  is  often  wise  to  begin  with  the 
water,  whether  plain  or  medicated,  at  95°  F.  and  reduce  the  temper- 
ature gradually  by  the  addition  of  cold  water  or  small  pieces  of  ice. 
It  is  rarely  necessary  to  go  below  60°  F.,  and  usually  the  sponging 
should  not  be  continued  longer  than  thirty  minutes.  It  is  well 
to  have  an  interval  of  rest — from  thirty  to  ninety  minutes — between 
the  spongings,  as  too  frequent  sponging,  if  resisted,  may  exhaust 
the  patient.  Every  part  of  the  body  should  be  sponged  in  turn, 
but  it  is  not  necessary  to  expose  the  patient,  who  should  be  covered 
with  a  flannel  blanket.  When  the  process  is  completed  the  skin 
should  be  briskly  rubbed  for  a  few  minutes  with  a  dry,  rough  towel. 

THE  COOL  PACK 

The  cool  pack  properly  applied  is  without  the  slightest  danger 
to  the  patient  and  is  the  best  means  we  possess  with  which  to  com- 
bat a  continued  high  fever.  It  may  be  used  as  freely  and  with 
as  much  success  in  the  exanthemata  as  in  typhoid  fever  or  pneu- 
monia. That  cool  water  may  not  safely  be  applied  to  the  skin  of 
a  child  with  scarlet  fever  or  measles  is  a  fallacy  which  it  is  our  duty 
to  explain  to  mothers. 

The  pack  is  prepared  as  follows,  a  rubber  sheet  being  used  to 
protect  the  bed-sheet:  A  large  bath  towel  or  some  thick,  soft,  absorb- 
ent material  should  be  used;  muslin,  linen,  or  any  thin  material  does 
not  answer  as  well.  Slits  are  cut  in  the  towel  large  enough  for  the 
arms  to  pass  through  and  the  towel  is  folded  around  the  body, 
enveloping  only  the  trunk  and  buttocks  (Fig.  54).  The  pack  should 
not  extend  below  the  middle  of  the  thighs.  This  leaves  the  arms 
and  the  greater  part  of  the  lower  extremities  free.  A  hot-water 
bag,  carefully  guarded,  should  be  placed  at  the  feet  and  the  patient 
covered  with  a  blanket  of  medium  weight.  The  towel  is  moistened 
with  water  at  95°  F.  This  higher  temperature  is  necessary  at  first 
31 


482  TEMPERATURE   IN    CHILDREN 

in  order  not  to  frighten  the  patient,  as  sudden  cold  is  apt  to  do, 
and  also  to  avoid  shock.  In  two  or  three  minutes  the  towel,  without 
being  removed,  is  again  moistened  with  water  at  90°  F.,  later  with 
water  at  85°  1'.,  and  still  later  at  80°  F.  When  the  temperature 
of  the  water  reaches  80°  F.,  it  is  better  to  hold  it  at  this  point 
for  half  an  hour,  when  the  patient's  temperature  should  again  be 
taken.  If  at  the  beginning  his  temperature  was  105°  F.  and  now 
shows  but  slight  or  no  reduction,  the  temperature  of  the  water 
with  which  the  towel  is  moistened  should  be  reduced  to  70°  F.,  or 
if  necessary,  even  to  60°  F.  The  child  throughout  need  not  be 
disturbed,  except  to  turn  him  from  side  to  side  to  wet  the  towel 
with  water  of  the  desired  temperature,  this  being  one  of  the  advan- 
tages of  the  pack  over  a  tub-bath  or  sponging. 

For  the  first  hour  or  two  in  a  pack  the  temperature  of  the  pa- 
tient should  be  taken  every  half  hour.  When  it  is  reduced  to  102° 
F.,  the  pack  should  be  removed,  for.  if  it  is  continued   longer,  too 


great  a  reduction  may  take  place.  If  it  rises  again  rapidly  to  105° 
F.  or  higher,  it  is  well  to  keep  the  patient  in  the  pack  continuously. 
The  degree  of  cold  necessary,  in  the  individual  case,  to  keep  the  tem'- 
perature  within  safe  limits  will  soon  be  learned.  I  recently  kept  in 
a  pack  for  seventy-two  hours  a  boy  four  years  old,  with  a  lobar 
pneumonia.  In  this  case  a  continuous  pack  of  70°  F.  was  required 
to  keep  the  temperature  at  104°  F.  or  slightly  lower.  The  towel, 
or  other  material  employed,  should  not  be  used  for  more  than  six 
hours,  when  it  should  be  changed  for  a  fresh  one. 

Another  reason  for  frequently  taking  the  temperature  is  that 
early  in  the  attack  we  do  not  know  how  it  will  be  affected  by  the 
continued  cool  applications.  In  some  children  it  is  very  readily 
influenced,  and  in  such  a  case  collapse  might  follow  a  very  sudden 
reduction  of  the  temperature.  In  cases  readily  controlled,  the  pack 
may  be  necessary  for  only  one-half  hour  or  an  hour,  at  intervals 
of  three  or  four  hours.     An  ice-bag  may  with  advantage  be  kept 


BATHING    THE    SICK  483 

at  the  head  when  the  child  is  in  the  pack.  Suddenly  enveloping 
the  entire  skin  surface  in  a  cold  sheet  at  70°  F.,  as  advocated  by 
some  writers,  may  increase  the  temperature  and  produce  grave 
symptoms  of  impending  death  because  of  the  sudden  contraction 
of  the  superficial  blood-vessels,  which  sends  the  blood  to  the  vis- 
cera, producing  congestion  of  the  internal  organs. 

BATHING  THE  SICK 
There  is  a  pronounced  objection  among  many  to  bathing  children 
when  ill,  particularly  when  they  are  suffering  from  respiratory 
diseases  or  from  the  exanthemata.  The  functions  of  the  skin  as  an 
organ  of  excretion  and  elimination  are  most  important,  and  it  is 
absolutely  necessary  that,  during  illness,  when  oftentimes  the 
metabolic  processes  of  the  body  are  being  carried  on  to  an  exces- 
sive degree,  all  the  eliminating  organs  be  kept  in  the  best  pos- 
sible condition  in  order  that  they  may  the  better  do  their  work. 
Therefore  to  have  the  skin  perform  its  functions  properly  it  must 
receive  proper  attention,  and  there  is  no  better  means  for  stimu- 
lating it  to  a  sharp  reaction  than  bathing  with  weak  salt  water 
— a  teaspoonful  of  salt  to  a  gallon  of  water — at  a  temperature 
of  85°  to  90°  F.,  followed  by  a  brisk  rubbing.  It  is  the  sudden 
contact  of  cold  air  with  the  moist  skin,  which  occurs  sometimes 
in  undressing  a  child,  without  the  attendant  reaction,  that 
causes  the  shock,  the  "cold,"  which  is  usually  attributed  to  the 
bath.  It  is  the  temperature  of  the  room  in  which  the  child  is  un- 
dressed, the  careless  method  of  bathing,  and  not  the  apphcation  of 
water  which  causes  the  trouble.  But  even  the  danger  of  this  ex- 
posure is  greatly  overestimated.  In  order  to  avoid  every  possible 
danger,  however,  the  temperature  of  the  room  in  which  the  sick  or 
deUcate  child  is  bathed  should  be  raised  to  80°  F.  I  have  yet  to 
know  of  a  child  who  suffered  from  the  effects  of  a  bath,  properly 
given. 


VACCINATION 

Every  infant  in  fair  health  should  be  vaccinated.  The  vaccina- 
tion should  be  done  as  soon  as  the  child  is  thriving  on  a  rational  diet. 
The  younger  the  child  at  the  time  of  vaccination,  the  less  the  consti- 
tutional disturbance.  In  well  infants,  vaccination  should  never  be 
delayed  beyond  the  fifth  month. 

The  Site. — The  site  selected  for  the  vaccination  is  usually  on  the 
left  arm  in  boys,  at  about  the  point  of  insertion  of  the  deltoid,  and  in 
girls  on  the  outer  aspect  of  the  calf  of  the  leg.  I  have  found,  how- 
ever, that  it  is  a  matter  of  much  more  convenience  to  the  mother  in 
dressing  and  handling  the  child,  if  the  leg  is  selected  in  both  sexes. 
The  dressing  is  more  easily  appHed  to  the  wound  and  can  the  more 
readily  be  kept  in  place  on  the  leg.  Further,  in  the  manipulation 
necessary  in  dressing  and  undressing,  much  less  discomfort  is  occa- 
sioned when  the  sore  is  on  the  leg. 

The  Method. — Before  scarification  of  the  skin,  the  site  selected 
should  be  well  scrubbed  with  common  soap  and  water,  dried,  and 
then  washed  with  alcohol.  The  area  of  scarification  should  not 
be  over  one-quarter  of  an  inch  in  diameter,  and  should  be  suffi- 
cient to  produce  only  a  light  flow  of  serum.  A  deep  scarification, 
producing  a  free  flow  of  blood,  is  very  apt  to  be  unsuccessful.  The 
best  scarifier  is  an  ordinary  sewing-needle,  which  should  be  sterilized 
by  placing  the  point  for  a  few  seconds  in  an  alcohol  flame.  The 
virus  which  is  furnished  in  hermetically  sealed  capillary  glass  tubes 
is  the  safest  to  use.  The  drop  of  virus  is  deposited  on  the  abraded 
surface  and  rubbed  well  into  the  wound,  using  the  side  of  the  needle 
for  this  purpose.  When  the  wound  is  thoroughly  dried,  a  protective 
dressing  should  be  appHed.  The  safest  and  most  convenient  is  a 
sterile  gauze  bandage,  which  is  wrapped  several  times  around  the 
arm  or  leg  and  secured  with  a  safety-pin.  On  account  of  the  shape 
and  position  of  the  parts,  the  bandage  is  very  apt  to  become  displaced, 
downward.  In  order  to  prevent  this,  a  strip  of  adhesive  plaster  one 
inch  wide  and  five  or  six  inches  long  is  placed  over  the  bandage  at 
right  angles  to  it.  The  middle  portion  of  the  plaster  readily  adheres 
to  the  bandage  and  the  two  ends,  at  least  two  inches  long,  are  an- 
chored to  the  skin. 

The  After-treatment. — The  mother  is  instructed  to  report  in  seven 
days  after  the  vaccination.  On  the  seventh  day  the  dressing  is  re- 
moved, and  if  the  vaccination  is  successful,  the  characteristic  pearl- 
like vesicle  will  be  present.  If,  on  account  of  accident  or  rubbing  of 
the  parts  by  the  patient,  the  vesicle  is  broken,  the  non-adhering 

484 


VACCINATION 


485 


gauze  should  be  carefully  cut  away  around  the  sore,  allowing  that 
which  adheres  to  remain.  Under  no  conditions  should  the  wound 
be  opened.  A  gauze  dressing  is  again  appHed  and  kept  in  position 
by  adhesive  strips.  At  the  end  of  the  exudative  stage,  usually  about 
five  or  six  days,  the  dressing  should  again  be  changed,  either  by 
the  mother  or  the  physician,  and  continued  until  the  crust  falls, 
which  will  be  from  the  third  to  the  fourth  week  after  the  vaccina- 
tion. 

If  there  is  no  sign  of  the  vesicle  in  ten  or  twelve  days,  the  vaccin- 
ation, if  primary,  should  be  repeated.  Re- vaccination  should  be 
practised  at  least  once  in  five  years  and  at  more  frequent  intervals 
during  epidemics  of  smallpox. 

If  vaccination  is  properly  performed,  the  dangers  attending  it  are 
practically  nil.  That  death  and  serious  results  have  followed  vaccin- 
ation is  no  argument  against  its  use,  but  is  a  grave  reflection  on  the 
manner  in  which,  as  a  rule,  it  is  performed.  The  scarification  of 
bacteria-laden  skin,  producing  at  the  outset  an  open  wound  which  is 
indifferently  or  not  at  all  protected  from  further  infection,  is  very  apt 
to  produce  complications  of  a  troublesome  and  often  serious  nature. 
Erysipelas,  extensive  cellulitis,  and  sloughing  of  the  parts  as  the  re- 
sult of  careless  vaccination  are  not  infrequently  seen  at  out-patient 
departments  for  children.  I  have  seen  in  two  cases  a  reinoculation, 
as  the  result  of  scratching  the  sore,  thus  transferring  the  virus  in  one 
case  to  the  upper  lip  and  in  the  other  to  the  left  upper  eyelid,  these 
places  being  the  site  of  the  vaccination  sore. 

There  is  not  a  vaccination  shield,  which  I  am  familiar  with,  on  the 
market  that  is  safe  for  use.  Some  cause  a  maceration  of  the  wound, 
others  allow  a  free  entrance  of  bacteria,  while  still  others  prevent  a 
free  superficial  circulation  of  the  blood  and  increase  the  chance  of 
ulceration.  Moreover,  the  shields  are  very  apt  to  become  displaced, 
causing  a  rupture  of  the  vesicle,  with  resulting  infection. 

A  certain  degree  of  constitutional  disturbance  is  present  in  every 
child  in  which  the  vaccination  is  successful.  After  the  first  month, 
however,  the  younger  the  child  the  less  the  constitutional  disturbance. 
Children  vaccinated  during  the  second  or  third  month  suffer  practi- 
cally no  inconvenience.  There  is  a  rise  in  temperature,  from  100*^ 
to  101°  F.,  for  a  day  or  two,  and  when  the  process  is  at  its  height,  per- 
haps a  slight  degree  of  restlessness.  Time  and  again  I  have  seen 
children,  vaccinated  at  this  age,  pass  through  the  various  stages 
without  manifesting  the  slightest  discomfort.  In  older  children  the 
severity  of  the  constitutional  symptoms  appears  to  increase  with  the 
age.  Thus,  a  child  in  the  second  or  third  year  may  have  fever,  102° 
to  104°  F.,  loss  of  appetite,  coated  tongue,  and  moderate  prostration. 
Very  active  symptoms  rarely  last  longer  than  three  days  unless  there 
is  a  considerable  accompanying  cellulitis. 

Active  treatment  other  than  relieving  the  immediate  constitu- 


486  VACCINATION 

tional  symptoms  is  rarely  required.  Even  when  there  is  an  active 
cellulitis  I  have  found  it  advisable  not  to  attempt  local  applica- 
tions, such  as  lotions  or  compresses.  Ointments  all  have  a  tendency 
to  dissolve  and  loosen  the  crust,  producing  an  open  wound.  When, 
on  account  of  suppuration,  the  crust  falls,  leaving  a  deep  ulcer 
formed  by  granulation  tissue,  active  local  treatment  will  be  required. 
Such  ulcers  are  often  seen  in  out-patient  work.  A  wet  dressing  of  a 
saturated  solution  of  boric  acid  has  answered  well  in  these  cases.  If 
the  wet  dressing  cannot  be  kept  properly  applied,  a  lo  percent  oint- 
ment of  boric  acid  may  be  applied  twice  a  day  and  will  be  found  of 
considerable  servdce  in  hastening  the  closure  of  the  wound.  The 
ointment  should  be  smeared  freely  on  gauze  or  clean  linen  and  held 
in  position  by  a  properly  applied  bandage.  In  young  children  the 
ulcers  are  often  most  obstinate.  In  a  few  instances  I  have  known 
them  to  continue  from  eight  to  ten  weeks.  In  a  case  in  which  the 
healing  is  particularly  slow,  the  familiar  dressing  of  balsam  of  Peru, 
5  percent,  in  castor  oil,  applied  twice  daily  on  a  pad  of  several  thick- 
nesses of  gauze  and  covered  with  oiled  silk,  has  appeared  to  hasten 
the  granulation.  Unhealthy  granulations  may  have  to  be  curetted 
before  the  dressing  is  applied. 


INSTRUCTIONS  FOR  THE  SUMMER 

In  addition  to  advising  parents  as  to  a  selection  of  a  summer  re- 
sort for  the  family,  I  advise  the  mother  as  to  the  particular  care  of 
the  child  during  the  summer  whether  he  is  to  remain  in  town  or  go 
to  the  country.  During  the  months  preceding  the  heated  term 
every  mother  whose  infant  is  under  my  care,  whether  in  dispensary 
or  private,  is  made  aware  of  the  dangers  of  the  next  few  months, 
and  means  are  suggested  and  written  directions  are  given  as  to  how 
to  pass  through  the  summer  with  the  greatest  security.  She  is 
told  what  market  milks  are  the  best.  She  is  told  that  the  milk 
must  be  kept  on  ice,  with  ice  surrounding  the  bottle,  from  the  time 
of  its  delivery  until  it  is  given  to  the  child,  except,  of  course,  the 
time  spent  in  its  special  preparation. 

During  the  hot  months  in  New  York  city  the  child's  digestive 
capacity  is  not  equal  to  that  of  the  colder  months.  Children  who 
remain  in  the  city  are  given  weaker  milk  mixtures  by  a  reduction  of 
from  15  to  25  percent  in  the  fat  and  proteid,  the  sugar  remaining 
the  same.  True,  the  infant  may  not  gain  very  much  in  weight,  but 
on  a  reduced  diet  he  is  much  more  apt  to  pass  through  the  summer 
without  intestinal  disorders,  and  there  is  an  abundant  opportunity 
for  him  to  gain  later  on.  Mothers  are  instructed  as  to  the  amount 
of  clothing  required.  They  are  told  that  a  napkin,  a  mushn  slip,  a 
loose-mesh  knitted  band,  are  all  that  are  required,  on  very  hot  days. 
They  are  instructed  to  give  the  infant  frequent  drinks  of  boiled 
water  between  his  feedings,  and  if  he  suffers  much  from  the  heat,  as 
shown  by  prickly  heat  and  restlessness,  to  give  him  two  or  three 
spongings  daily  with  a  cool  solution  of  bicarbonate  of  soda,  one  tea- 
spoonful  to  a  pint  of  water. 

It  is  made  very  plain  to  them  that  vomiting  or  a  green  undigested 
stool  is  a  danger-signal  which  always  means  that  the  milk  must  be 
withheld  for  twenty-four  hours  or  longer  whether  the  child  is  nursed 
or  bottle-fed,  and  that  either  barley-water  or  one  of  the  other  carbo- 
hydrate gruels  (page  119)  must  be  substituted  until  such  time  as 
the  stools  improve  or  the  vomiting  ceases.  This  is  one  of  the  most 
important  life-saving  measures  the  physician  can  teach  the  mother. 
An  immense  majority  of  the  intestinal  diseases  of  summer  which 
destroy  thousands  of  lives  yearly,  have  their  origin  in  a  neglected 
acute  indigestion  and  diarrhea,  which  if  properly  managed  means  a 
slight  illness  of  but  a  day  or  two.  Therefore  it  is  further  impressed 
upon  the  mothers  that  upon  resuming  the  milk  diet,  it  must  be  given 
at  first  greatly  reduced   in  strength  and  then  gradually  increased 

487 


488  INSTRUCTIONS   FOR   THE    SUMMER 

until  food  of  the  previous  strength  is  given.  Beginning  with  one-half 
ounce  of  skimmed  milk  in  each  feeding,  by  watching  its  effects  upon 
the  temperature  and  the  stools,  an  increase  of  perhaps  one-half  ounce 
may  be  made  each  day. 

I  have  experienced  not  a  little  trouble  in  the  past  in  securing  safe 
milk  for  infants  who  were  removed  at  a  considerable  distance  from 
the  depots  of  the  better  class  of  dairies  that  supply  certified  milk. 
The  average  farmer  is  notoriously  careless  in  the  handling  of  milk, 
and  in  the  country  districts,  where  the  milk-supply  should  be  the  best, 
it  is  often  as  bad  as  can  well  be  imagined.  In  remote  country  dis- 
tricts where  the  milk  is  furnished  by  the  farmer  a  special  arrange- 
ment is  made,  by  which  he  agrees  that  the  cow's  belly,  udders,  and 
teats  shall  be  wiped  off  with  a  damp  cloth  before  milking;  that  the 
milker's  hands  shall  be  washed  before  milking;  that  the  few  jets  of 
the  fore-milk  shall  be  thrown  away ;  and  that  as  soon  as  the  milk  is 
drawn  it  shall  be  strained  through  absorbent  cotton  into  a  quart 
milk  bottle,  suitably  corked,  and  placed  in  a  pail  of  cracked  ice.  A 
mother  of  one  of  my  patients  is  using  her  silver  champagne-cooler 
for  this  purpose  at  the  present  time!  The  cracked  ice  and  the  ab- 
sorbent cotton  are,  of  course,  furnished  by  the  consumer.  For  the 
extra  trouble  the  farmer  receives  from  twelve  to  twenty  cents  a 
quart  for  the  milk.  At  one  resort  three  babies  were  supplied  in  this 
way  by  one  small  producer,  with  a  comparatively  safe  milk.  The 
improved  milk-pail  (Figs.  12,  13)  insures  a  much  cleaner  milk,  as  it 
offers  much  less  opportunity  for  droppings  to  fall  into  it  during  the 
milking. 

For  those  who  have  country  homes  and  who  can  control  their 
milk-supply  the  above  precautions  may  be  carried  out  to  the  letter. 
By  such  careful  control  of  the  home  product,  and  by  the  use  of  milk 
from  those  dairies  only  which  observe  the  above  precautions,  the  acute 
digestive  disorders  of  summer  among  my  patients  are  rendered  a  very 
unusual  occurrence.  These  precautions,  with  the  knowledge  of  the 
mother  or  nurse  as  to  what  to  do  at  the  first  sign  of  a  digestive  dis- 
order, will  reduce  the  number  of  the  so-called  summer  diarrhea  cases 
to  a  very  insignificant  figure. 

Among  out-patients  in  large  cities  who  have  to  use  other  milk 
and  milk  less  clean,  summer  diarrhea  must  prevail.  Among  these, 
however,  the  death-rate  may  be  remarkably  reduced  through  the 
education  of  the  mothers.  At  the  out-patient  department  at  the 
Babies'  Hospital  there  is  a  very  low  death-rate  from  summer  diar- 
rhea. At  this  dispensary  there  is  a  clientele  of  fairly  intelligent 
mothers  who  have  been  coming  to  us  for  years.  By  pamphlets 
of  instructions  as  given  below,  and  by  showing  these  mothers 
that  we  have  a  personal  interest  in  their  children,  we  gain  their  con- 
fidence. They  believe  what  we  tell  them,  and,  as  a  result,  we  re- 
peatedly have  children  brought  to  us  well  along  the  road  to  recovery. 


INSTRUCTIONS   FOR    THE    SUMMER  48^ 

For  example,  a  child  had  developed  diarrhea;  he  had  been  given 
a  dose  of  castor  oil,  his  milk  was  stopped  and  barley-water  or  rice- 
water  given.  The  mothers  are  further  told  that  it  is  never  a  good 
thing  for  a  baby  to  have  diarrhea ;  that  a  diarrhea  is  never  without 
dangers;  and  that  an  infant  who  has  frequent  attacks  of  indigestion 
during  the  cooler  months  is  very  sure  to  develop  diarrhea  during  the 
hot  months ;  and  that  the  safest  means  of  keeping  a  baby  well  in  the 
summer  is  to  keep  him  well  all  the  year  round. 


Rules  for  the 

CARE  OF  DISPENSARY  INFANTS  AND  YOUNG  CHILDREN 

During  the  Summer. 

1.  Clothing:  During  the  very  hot  days  the  baby  should  wear  a 
napkin,  a  thin  gauze  shirt,  and  a  thin  muslin  slip;  an  abdominal 
binder  made  of  thin  material,  and  loosely  applied,  maybe  worn  until 
the  child  is  six  months  of  age.  After  this  age  the  binder  is  not  nec- 
essary. 

2.  Bathing:  Every  child  should  have  one  tub-bath  daily.  On 
very  warm  days  from  two  to  four  ten-minute  spongings  with  cool  soda 
water  (one  teaspoonful  of  bicarbonate  of  soda  to  a  pint  of  water) 
will  greatly  add  to  the  child's  comfort. 

3.  Fresh  Air:  Fresh  air  is  of  vital  importance.  Leave  the  win- 
dows open.  Keep  the  child  in  the  open  air  when  possible.  Avoid 
the  sun.  Select  the  shady  side  of  the  street  and  the  shade  in  the 
parks. 

4.  Sleep:  Sleep  is  very  necessary  for  growing  children.  A  noon- 
day nap  of  at  least  two  hours  should  be  insisted  upon  until  the  child 
is  four  years  of  age. 

5.  Soiled  Napkins:  Soiled  napkins  should  be  placed  in  some  cov- 
ered receptacle  containing  water,  and  washed  at  the  earliest  oppor- 
tunity. 

6.  Drinking-water :  Boil  one  quart  of  water  every  morning.  Put 
it  into  a  clean  bottle.  Keep  the  bottle  in  a  cool  place.  Give  the 
water  between  the  feedings,  as  much  as  the  child  will  take. 

7.  Breast-feeding:  The  mother  should  wash  the  nipple  with  plain 
cold  water  before  each  nursing.  She  should  be  very  careful  as  to 
diet  and  the  habits  of  life.  The  bowels  should  move  once  a  day. 
Constipation  in  the  mother  prpduces  illness  in  the  child.  There 
should  be  three  plain,  well-cooked  meals  daily,  consisting  largely  of 
milk,  meat,  vegetables,  and  cereals.  Beer  and  tea  are  often  harmful. 
A  large  quantity,  a  couple  of  pints  or  more  daily  of  either,  is  positively 
dangerous. 

From  birth  to  the  third  month:  The  baby  should  be  nursed  at  two 
and  one-quarter  hour  intervals  during  the  day.     Nine  nursings  in 


490  INSTRUCTIONS   FOR  THE   SUMMER 

twenty-four  hours,  with  only  one  nursing  between  10.30  p.  m.  and 
6  A.  M. 

Third  to  sixth  month :  The  nursings  should  be  at  three-hour  intervals 
during  the  day ;  seven  to  eight  nursings  in  twenty-four  hours,  with  one 
night  nursing. 

Sixth  to  ninth  month:  The  child  now  takes  a  larger  quantity  at 
each  feeding  and  the  night  nursing  is  not  necessary.  He  should  be 
nursed  at  three  to  three  and  one-half  hour  intervals ;  six  nursings  in 
twenty-four  hours. 

Ninth  to  twelfth  month:  The  nursings  should  be  at  three  and  one- 
half  to  four-hour  intervals,  five  nursings  in  twenty-four  hours. 

8.  Bottle-feeding:  The  bottle  should  be  thoroughly  cleansed  with 
borax  and  hot  water  (one  teaspoonful  of  borax  to  a  pint  of  water) 
and  boiled  before  using.  The  nipple  should  be  turned  inside  out, 
scrubbed  with  a  brush,  using  hot  borax  water.  The  brush  should 
be  used  for  no  other  purpose.  There  should  be  three  or  four  sets  of 
bottles  and  nipples.  The  bottles  and  nipples  should  rest  in  plain 
boiled  water  until  wanted.  Never  use  grocery  milk.  Use  only 
bottled  milk  w^hich  is  delivered  every  morning.  The  milk  should  be 
boiled  for  five  minutes  immediately  after  receiving.  The  feeding 
hours  are  the  same  as  in  breast-feeding.  Children  of  the  same  age 
vary  greatly  as  to  the  strength  and  amount  of  food  required.  A 
mixture,  when  prepared,  should  be  poured  into  a  covered  glass  fruit- 
jar  and  kept  on  the  ice.  For  the  average  baby  the  following  mix- 
tures will  be  found  useful : 

For  a  child  under  three  months  of  age:  Nine  ounces  of  milk,  twenty- 
seven  ounces  of  boiled  water,  four  teaspoonfuls  of  granulated  sugar. 
Feed  from  two  to  four  ounces  at  two  and  one-quarter-hour  intervals — 
nine  feedings  in  twenty-four  hours. 

Third  to  sixth  month:  Eighteen  ounces  of  milk,  thirty  ounces  of 
barley-water,  six  teaspoonfuls  of  sugar.  Feed  four  to  six  ounces  at 
three-hour  intervals — seven  feedings  in  twenty-four  hours. 

The  barley-water  is  prepared  by  boiling  a  tablespoonful  of  Rob- 
inson's barley  flour  or  Cereo  Co.'s  barley  flour  in  one  pint  of  water  for 
twenty  minutes;  strain  and  add  water  to  make  one  pint. 

Sixth  to  ninth  month:  Twenty-four  ounces  of  milk,  twenty-four 
ounces  of  barley-water,  six  teaspoonfuls  of  granulated  sugar.  Feed  six 
to  eight  ounces  at  three-hour  intervals — six  feedings  in  twenty-four 
hours. 

Ninth  to  twelfth  month:  Thirty-eight  ounces  of  milk,  twelve  ounces 
of  barley-water,  six  teaspoonfuls  of  granulated  sugar.  Feed  seven  to 
nine  ounces  at  three  and  one-half  hour  intervals — five  feedings  in 
twenty-four  hours. 

9.  Condensed  Milk:  When  the  mother  cannot  afford  to  buy  bot- 
tled milk,  when  she  has  no  ice-chest  or  cannot  afford  to  buy  ice,  she 
should  not  attempt  cow's-milk  feeding,  but  canned  condensed  milk 


SUMMER    RESORTS  49I 

may  be  used  as  a  substitute  during  the  hot  months  only.  The  can, 
when  opened,  should  be  kept  in  the  coolest  place  in  the  apartment, 
carefully  wrapped  in  clean  white  paper.  The  feeding  hours  are  the 
same  as  for  fresh  cow's  milk. 

Under  three  months  of  age:  One-half  to  one  teaspoonful  condensed 
milk;  barley-water  No.  i  (see  formulary,  page  123),  two  to  four 
ounces. 

Third  to  sixth  month:  Condensed  milk,  one  to  two  teaspoonfuls; 
barley-water,  four  to  six  ounces. 

Sixth  to  ninth  month:  Condensed  milk,  two  to  three  teaspoonfuls; 
barley-water,  six  to  eight  ounces. 

Ninth  to  twelfth  month:  Condensed  milk,  three  teaspoonfuls; 
barley-water,  eight  to  nine  ounces. 

10.  Feeding  after  one  year  of  age:  All  children  should  be  weaned 
at  the  age  of  twelve  months  unless  otherwise  ordered  by  a  physician. 
The  bottle-fed,  also,  at  this  age  require  more  than  milk  and  cereal 
water.  During  the  second  year  children  are  almost  invariably  badly 
fed. 

Four  meals  a  day  should  be  given  at  the  same  hours  every  day. 
The  mother  will  select  suitable  meals  from  the  following  articles: 
soft-boiled  egg;  scraped  rare  beef;  strained  broth  of  beef,  mutton, 
or  chicken  with  stale  bread  broken  into  it;  toast  and  butter;  stale 
bread  and  butter;  toast  and  milk;  stale  bread  and  milk;  oatmeal 
(cooked  three  hours)  and  milk;  hominy  (cooked  three  hours)  and 
milk;  cornmeal  (cooked  two  hours)  and  milk;  farina  (cooked  one 
hour)  and  milk.  The  milk  used  must  be  boiled,  during  the  hot 
weather. 

11.  Summer  Diarrhea:  When  the  baby  has  loose  green  passages 
it  means  that  he  is  sick  and  needs  medical  attention.  The  disease  is 
frequently  mild  at  the  beginning.  There  may  be  no  fever  and  the 
child  may  show  no  signs  of  illness  other  than  the  diarrhea.  Such  a 
baby  oftentimes,  with  milk-feeding  continued,  becomes  dangerously, 
if  not  fatally,  ill  in  a  very  few  hours.  The  simplest  cases  of  vomit- 
ing and  diarrhea  during  the  summer  must  never  be  neglected.  A 
baby  sick  in  this  way  should  be  given  two  teaspoonfuls  of  castor  oil. 
Stop  the  milk  at  once.  Give  only  barley-water  or  rice-water  until 
the'  child  can  be  taken  to  the  family  physician  or  to  a  dispensary, 

SUMMER  RESORTS 

Where  to  take  a  baby  for  the  hot  months  of  the  year  is  a  vexed 
question  which  is  raised  in  many  citv  households  every  year,  and  it 
is  one  concerning  which  the  physician  is  frequently  called  upon  for 
advice.  Several  years  of  observation  of  a  great  many  New  York  city 
children  who  have  spent  the  summer  out  of  town  have  led  me  to  the 
following  conclusions : 

First,  the  most  desirable  summer  outing  is,  the  first  half  of  the 


492  INSTRUCTIONS  FOR   THE)    SUMMER 

season  at  the  seashore,  the  remainder  inland,  preferably  in  the  moun- 
tains. 

Second,  the  next  place  in  order  of  desirability  is  inland,  preferably 
the  mountains,  for  the  entire  summer. 

Third,  the  least  desirable  is  the  seashore  for  the  entire  summer. 

It  is  not  to  be  understood  that  many  children  will  not  do  well 
if  kept  at  the  seashore  throughout  the  hot  months.  Some,  indeed, 
improve  most  satisfactorily,  but  among  my  own  patients  I  have  re- 
peatedly been  impressed  with  the  disadvantages  of  a  too  prolonged 
stay  at  the  seashore.  If  kept  there  during  August,  infants  are  apt 
to  show  signs  of  lassitude,  and  while  not  ill,  they  do  not  return  to  the 
city  in  the  autumn  with  the  vigor,  appetite,  and  general  robustness 
which  characterize  those  from  the  hills  and  mountains.  It  must  be 
remembered  that  only  New  York  city  children  are  referred  to.  Chil- 
dren whose  home  is  a  seaport  thrive  best  when  given  the  benefit  of 
a  complete  change  to  the  dry,  invigorating  air  inland.  Children  with 
catarrhal  tendencies,  bronchitis,  adenoids,  before  or  following  opera- 
tion, and  children  who  have  had  attacks  of  rheumatism  or  who  show 
rheumatic  tendencies,  should  not  go  to  the  seashore,  wherever  their 
residence.  In  referring  to  an  inland  resort,  the  mountains,  by  which 
we  understand  an  elevation  of  from  1500  to  2000  feet,  are  not  always 
necessarv.  The  place  selected,  however,  should  be  at  an  elevation 
of  at  least  600  feet.  For  cases  of  chronic  bronchitis  and  rheumatism, 
a  soil  of  sand  or  gravel  is  best,  and  the  sleeping-room  of  the  child 
should  always  be  above  the  ground  floor. 

Other  points  to  be  considered  in  connection  with  the  summer 
outing  are  the  kitchen  facilities,  which  must  be  ample.  Often  the 
larger  hotels  refuse  the  right  of  way  to  the  kitchen.  I  find  that  in 
this  respect  much  more  liberty  is  given  in  the  smaller  hotels  and 
boarding-houses.  The  proper  preparation  of  the  child's  food  in  the 
cramped  quarters  of  sleeping-rooms  is  not  impossible,  but  it  is  often 
difficult  and  always  objectionable;  therefore  if  a  cottage  is  available, 
it  will  be  greatly  to  the  child's  advantage.  Before  selecting  a  home 
for  the  summer,  the  drainage  and  the  source  and  quality  of  its  milk- 
supply  should  receive  the  most  careful  attention.  Country  well- 
water  or  spring-water  should  invariably  be  boiled  before  using. 


THERAPEUTIC  MEASURES 

COUNTER-IRRITANTS 

The  counter-irritants  which  I  have  found  especially  useful  in  pedi- 
atrics are  mustard,  capsicum,  turpentine,  camphor,  chloroform,  and 
iodin. 

Counter-irritants  are  useful  in  children  for  two  purposes — for  the 
relief  of  pain  and  for  the  effect  upon  internal  inllammation  and  con- 
gestion. Without  doubt  the  diseased  conditions  in  which  counter- 
irritation  is  of  most  value  are  in  the  acute  affections  of  the  respira- 
tory tract,  such  as  bronchitis,  bronchopneumonia,  and  pleurisy.  In 
acute  bronchitis,  when  the  terminal  bronchi  are  involved,  when  there 
is  cyanosis  and  rapid  respiration — from  sixty  to  eighty  per  minute — 
enveloping  the  thorax  in  a  mustard  plaster,  one  part  mustard  to 
two  of  flour  (see  page  259),  and  keeping  it  in  position  until  the 
skin  is  well  reddened,  will  often  reduce  the  respirations  from  twenty 
to  thirty  per  minute,  and  the  child,  previously  tossing  and  restless, 
will  fall  asleep.  I  have  repeatedly  been  asked  by  nurses  and  mothers 
if  the  counter-irritation  could  not  be  applied  more  frequently  because 
of  the  apparent  relief  experienced  by  the  patient.  The  applications 
may  often  be  made  with  advantage  at  intervals  of  from  four  to  six 
hours.  They  should  be  sufficiently  strong  to  produce  the  desired  red- 
ness of  the  skin  in  from  live  to  ten  minutes.  This  will  usually  be 
produced  by  using  one  part  of  mustard  to  two  of  flour,  when  the 
applications  are  first  used.  When  the  skin  becomes  tender  from 
the  repeated  applications,  but  one  part  of  mustard  to  five  or  six  of 
the  flour  may  be  required.  If  the  plaster  is  made  too  weak,  it  must 
remain  long  in  contact  with  the  skin,  which  thereby  becomes  macer- 
ated. 

Indications. — In  Acute  Inflammations  of  the  Respiratory  Tract. — 
When  the  bronchitis  is  of  the  asthmatic  type,  when  there  is  decided 
bronchial  spasm  associated  with  bronchial  catarrh,  the  counter- 
irritation  furnishes  not  a  little  relief.  In  this  condition  the  whole 
thorax  should  be  enveloped.  In  bronchopneumonia  with  consid- 
erable bronchitis,  local  applications  of  mustard  over  the  involved 
areas  are  to  be  advised.  The  pain  from  pleuritic  inflammation  oc- 
curring independently  of  or  at  the  onset  of  lobar  pneumonia,  or 
when  it  develops  during  bronchopneumonia,  may  be  considerably 
relieved  by  counter-irritation.  Here  also  the  mustard  should  be 
used  only  over  the  painful  area.  When  the  pain  is  severe,  equal  parts 
of  mustard  and  flour  may  be  used  for  the  first  application,  if  carefully 


494  THERAPEUTIC   MEASURES 

watched,  for  a  quick,  sharp  skin  reaction  should  be  produced.  If 
there  is  any  further  action  than  that  of  a  sedative  through  retarding 
the  inflammatory  process  within,  we  have  no  means  of  proving  it. 
The  mother  or  nurse  should  always  be  cautioned  to  watch  the  skin 
under  a  counter-irritant  so  that  a  bUster  shall  not  be  produced. 

During  the  stage  of  engorgement  and  congestion  of  the  bronchi, 
indicated  by  roughened  or  sonorous  breathing  with  occasional  sibilant 
rales,  a  brisk  counter-irritation  with  mustard,  or  with  camphorated 
oil  and  turpentine,  appears  to  hasten  the  progress  of  the  case  toward 
recovery.  That  a  respiratory  disease  is  ever  aborted  by  these 
methods,  as  claimed  by  some,  is  exceedingly  doubtful.  If  the  tur- 
pentine is  used  with  the  camphorated  oil,  the  proportion  should  be 
one  part  of  turpentine  to  two  parts  of  the  camphorated  oil.  The 
mixture  should  be  well  shaken  before  use  and  applied  with  the  hand 
vigorously  for  ten  minutes  or  until  a  distinct  redness  of  the  skin  is 
produced.  The  mustard  or  the  turpentine  should  be  used  in  these 
cases  at  least  three  times  a  day.  I  know  of  no  condition  when  it  is 
necessary  to  blister  a  child's  skin.  Capsicum  vaselin  may  be  used 
in  the  same  way  and  for  the  same  purpose  as  the  camphorated  oil 
and  turpentine. 

In  Colic. — In  severe  colic  a  turpentine  stupe  will  often  furnish 
prompt  relief,  twenty  drops  of  turpentine  being  mixed  with  one  pint 
of  water  at  io6°  F.  Into  this  a  piece  of  flannel  is  dipped  and  wrung 
sufficiently  dry  not  to  moisten  the  bed-clothing  and  placed  over  the 
abdomen.  Over  this  is  placed  a  dry  flannel  and  oiled  silk  so  as  to 
retain  the  heat  and  moisture.  The  application  may  be  renewed 
every  fifteen  or  twenty  minutes  if  necessary. 

In  Pleurisy  and  Empyema. — When  adhesions  exist  in  empyema 
and  pleurisy,  while  the  pain  is  not  acute,  there  is  an  uncomfortable 
drawing,  dragging  sensation  in  the  chest  which  may  persist  for 
months.  This  has  been  relieved  in  a  few  of  my  cases  by  the  tincture 
of  iodin,  U.  S.  P.,  painted  over  the  painful  parts  every  third  or  fourth 
night. 

In  Intercostal  Neuralgia. — In  intercostal  neuralgia,  not  infre- 
quently seen  in  overworked  school-girls,  the  repeated  application  at 
interv^als  of  three  or  four  days  of  tincture  of  iodin  over  the  point  of 
exit  of  the  involved  nerve,  will  often  be  followed  by  complete  cessa- 
tion of  the  pain.  For  the  pain  in  acute  articular  rheumatism,  chloro- 
form liniment,  U.  S.  P.,  may  be  applied  to  the  joint. 

ANESTHETICS 
That  the  use  of  anesthetics  in  children  is  attended  with  consider- 
able danger  is  proved  by  the  statistics  relating  to  the  subject.  That 
the  greatest  care  and  judgment  should  be  exercised  in  the  selection 
of  an  anesthetic  for  a  child  is  readily  understood.  As  a  routine  an- 
esthetic for  the  3^oung,  ether  is  preferable  because  of  its  safety.     The 


,  ANESTHETICS  495 

popular  belief  that  chloroform  is  without  danger  is  an  error  and  not 
sustained  by  statistics.  There  are  conditions,  however,  when  ether 
is  contraindicated.  In  cases  in  which  there  is  bronchial  involvement, 
ether  increases  the  bronchial  secretions  and  produces  a  free  flow  of 
saliva,  which  is  hable  to  be  aspirated  into  the  lungs.  In  case  of  any 
obstruction  to  respiration,  as  in  laryngeal  diphtheria,  retropharyngeal 
abscess,  and  enlarged  glands  which  may  encroach  upon  the  air- 
passages,  chloroform  and  not  ether  should  be  employed.  Ether  is 
further  contraindicated  in  scarlet  fever  or  in  nephritis.  In  such 
cases  chloroform  is  to  be  selected.  Chloroform  is  to  be  used  also  for 
the  sake  of  convenience,  if  other  conditions  allow,  in  operations  about 
the  mouth  and  the  nose.  Chloroform  is  contraindicated  in  general 
weakness,  exhaustion,  collapse,  and  in  anemia.  Ether  given  by  the 
drop  method  should  be  used  in  those  cases.  Statistics  of  chloroform 
anesthesia  show  a  considerable  mortality  in  operations  for  adenoids 
and  enlarged  tonsils.  The  interference  with  respiration  and  the  sud- 
den hemorrhage  make  chloroform  dangerous  in  these  operations.  In 
heart  disease  with  imperfect  compensation,  any  anesthetic  is  dan- 
gerous, but  ether  by  the  drop  method  is  the  least  so.  Nitrous  oxid 
gas,  which  of  late  has  become  very  popular,  should  be  used  with  cau- 
tion in  children  under  two  years  of  age.  Young  children  are  very 
easily  asphyxiated  by  gas;  the  younger  the  child,  the  greater  the 
danger.  Under  two  years  of  age,  sudden  and  alarming  asph\Tcia 
has  resulted  from  its  use.  It  should  be  used,  therefore,  very  spar- 
ingly and  the  patient  watched  most  carefully  for  signs  of  cyanosis. 
The  use  of  gas  in  children  usually  precedes  the  administration  of 
ether,  as  it  renders  the  use  of  the  latter  much  easier  for  the  patient. 
It  is  contraindicated,  however,  in  any  condition  where  dyspnea 
is  present;  in  fact,  in  any  illness  in  which  respiration  is  impeded, 
gas  is  dangerous.  The  combination  of  gas  and  ether  in  such  cases 
is  not  as  safe  as  chloroform,  which  is  to  be  given  in  a  minimum 
amount  with  oxygen  as  a  safeguard. 

Danger-signals  During  Gas  Administration : 

Cyanosis;  jerking  respirations;  dilated  pupils;  convulsive 
movements  of  any  portion  of  the  body. 

Danger-signals  with  Chloroform  : 

Pallor;  ashen  color;  feeble,  shallow  respirations,  gasping  in 
character;  dilated  pupils  and  separation  of  the  eyelids; 
slow,  feeble  heart  action. 

Danger-signals  with  Ether : 

Marked  cyanosis;  stertorous  breathing;  rapid  pulse;  dilated 
pupils;  short,  quick,  gasping  respiration. 

The  use  of  ethyl  chlorid  is  in  the  experimental  stage.  Statistics 
show  quite  a  mortahty  from  its  use.  In  case  the  condition  of  the 
patient  shows  any  of  the  danger-signals,  it  should  temporarily  or 
permanently  be  discontinued  and  some  other  form  of  anesthetic 
substituted. 


496  THERAPEUTIC  MEASURES 


COLON  FLUSHING 

In  colon  flushings  a  normal  salt  solution  should  invariably  be 
used.  It  is  given  with  the  idea  of  having  it  retained  and  absorbed 
for  the  purpose  of  furnishing  needed  fluid  to  the  body.  It  may  be  of 
service  in  any  case  in  which  but  little  fluid  is  taken  by  the  mouth. 
It  has  been  particularly  serviceable  in  severe  cases  of  scarlet  fever, 
diphtheria,  pneumonia,  and  cyclic  vomiting,  when  little  fluid  was 
taken,  or  if  taken,  was  not  retained.  The  large  amount  of  fluid 
which  the  colon  will  absorb  when  the  organism  demands  it  is  sur- 
prising. 

In  a  case  of  cyclic  vomiting,  a  boy,  who  had  retained  absolutely 
nothing  given  by  mouth  for  three  days,  retained  one  pint  at  the 
first  colon  flushing,  one-half  pint  more  after  six  hours,  and  a  sec- 
ond half -pint  six  hours  later.  The  flushings  were  begun  on  the  third 
day  of  the  attack.  Although  the  prostration  was  extreme,  the 
prompt  improvement  in  the  general  condition  of  this  patient  was 
most  gratifying.  After  the  first  injection  the  pulse  improved,  the 
apathy  disappeared,  the  child  began  to  ask  questions  and  showed 
interest  in  his  surroundings. 

Severe  toxic  cases  of  diphtheria  and  scarlet  fever,  where  but  little 
fluid  is  taken  and  where  the  toxicity  of  the  blood  is  extreme,  as 
shown  by  the  stupor  and  delirium,  are  often  much  improved  by  the 
free  use  of  colon  flushing,  which  supplies  the  water  which  the  child 
needs  but  which  cannot  be  given  by  mouth,  or  if  given  may  not  be 
retained. 

A  boy  nine  years  of  age,  ill  with  scarlet  fever,  who  could  take 
very  little  fluid,  was  able  to  retain  eight  ounces  of  a  salt  solution 
given  at  eight-hour  intervals  for  three  days. 

A  child  six  months  of  age  had  retained  absolutely  nothing  on  the 
stomach  for  six  days,  because  of  intussusception.  When  I  saw  him 
on  the  sixth  day,  the  respiration  was  superficial  and  slow.  He  was 
cold  and  practically  pulseless.  The  second  heart-sound  could  be 
heard  but  faintly  with  the  stethoscope.  The  intussusception,  greatly 
to  my  surprise,  was  reduced  by  water-pressure  (page  212).  Hot 
salt-water  flushings  were  at  once  begun;  the  patient  retained  ten 
ounces,  given  at  a  temperature  of  1 10°  F.,  and  in  a  few  minutes  there 
was  a  very  perceptible  improvement.  With  repeated  flushings  at 
six-hour  intervals  the  child  continued  to  improve,  and  made  a  perfect 
recovery. 

I  usually  order  the  salt  solution  given  in  quantities  of  from  one- 
half  pint  to  a  pint,  depending  upon  the  age  of  the  child,  at  mtervals 
of  from  six  to  eight  hours,  but  never  at  a  lower  temperature  than 
100°  F. 

The  apparatus  required  is  a  small  rectal  tube  attached  to  a  foun- 
tain syringe.     The  flushing  is  best  given  with  the  patient  resting  on 


AIvCOHOL  497 

his  left  side  with  the  buttocks  elevated  on  a  pillow,  the  tube,  well 
oiled,  being  introduced  at  least  nine  inches  into  the  bowel.  The 
solution  is  allowed  to  pass  into  the  bowel,  when  the  tube  is  quickly 
withdrawn.  To  assist  in  the  retention  of  the  fluid,  the  patient 
should  remain  on  his  side  for  one-half  hour. 

ALCOHOL 

In  its  relation  to  children,  alcohol,  regardless  of  the  form  in  which 
it  is  used,  must  always  be  considered  as  a  drug  and  not  as  a  beverage. 
It  is  occasionally  of  great  service  in  diseases  of  children.  Under 
certain  conditions  it  answers  better  than  any  other  means  of  stimu- 
lation we  possess.  The  fact  that  it  is  grossly  misused  does  not  in  any 
way  detract  from  its  value  in  illness.  It  is  too  often  given,  chiefly 
for  the  reason  that  its  use,  in  the  form  of  whisky  and  brandy  and 
wine,  is  advocated  in  medical  works  in  many  of  the  ordinary  ail- 
ments of  childhood  where  really  it  is  absolutely  contraindicated. 
Its  use,  in  my  hands,  has  been  that  of  a  food  and  stimulant  in 
very  grave  conditions,  the  duration  of  its  usefulness  being  often 
completed  in  a  day  or  two.  When  given  to  children  for  a 
prolonged  period  even  in  moderate  quantities,  it  invariably  inter- 
feres with  digestion  and  assimilation,  and  therefore  does  harm. 
It  is  very  liable  also  to  act  as  an  additional  irritant  to  the  kidneys, 
which  are  prone  to  show  inflammatory  changes  as  a  result  of  the 
systemic  toxemia,  due  to  the  disease.  We  have  heart  stimulants 
which  are  ordinarily  as  effective  as  alcohol  and  without  its  danger 
either  to  the  stomach  or  the  kidneys. 

It  is  my  practice  never  to  give  alcohol  early  in  an  illness,  unless 
the  onset  is  accompanied  by  profound  prostration,  but  rather  to 
hold  it  in  reserve  until  absolutely  necessary.  Used  in  this  way,  it 
has  been  of  much  service  in  two  conditions  in  which,  in  my  opinion, 
nothing  can  replace  it.  I  refer,  first,  to  that  time  which  may  arise 
in  any  grave  disease  when  the  heart  fails  to  respond  to  the  usual 
stimulation,  as  in  the  crisis  of  lobar  pneumonia,  and  in  the  profound 
toxemia  of  scarlet  fever  or  diphtheria.  At  these  times  the  powers 
of  assimilation  for  most  drugs  as  well  as  for  food  are  reduced  to  a 
minimum.  When  food  is  rejected  or  taken  badly,  when  the  useful- 
ness of  strychnin,  strophanthus,  musk,  camphor,  and  digitalis  has 
been  exhausted,  then  give  alcohol,  and  give  it  in  as  large  doses  as 
may  be  required  to  produce  the  desired  results.  It  is  astonishing 
what  large  quantities  of  alcohol  may  be  given  without  the  slightest 
intoxicating  effects  in  many  such  conditions.  When  given  well 
diluted  it  is  usually  well  borne  and  assimilated,  it  supports  the  heart, 
improves  the  respiration  and  often  will  carry  the  patient  through 
to  a  successful  convalescence  even  when  the  outlook  is  very  un- 
promising. As  the  system  readily  becomes  accustomed  to  alcohol, 
it  must  be  given  in  increasing  doses.  If  it  is  begun  early  in  the  ill- 
32 


498  THERAPEUTIC    MEASURES 

ness,  it  will  have  lost  its  stimulating  effects  by  the  time  it  is  most 
needed.  Brandy  or  whisky,  well  diluted,  is  the  form  in  which  it  is 
generally  used. 

The  second  condition  in  which  alcohol  is  useful  is  in  cases  with 
greatly  lowered  vitality  resulting  from  some  severe  illness,  such  as 
typhoid  fever,  enterocohtis,  or  pneumonia.  With  a  child  suffering 
from  shock  bordering  on  collapse,  or  when  in  collapse  with  a  sub- 
normal temperature  with  all  the  vital  powers  at  a  low  ebb,  alcohol 
will  do  much  to  sustain  him.  In  such  cases  whisky,  well  diluted — 
I  part  whisky  to  6  of  water — given  at  intervals  of  two  or  three  hours, 
will  hasten  recovery.  If  the  child  cannot  swallow,  the  whisky  may 
be  given  by  gavage;  if  vomited,  double  the  quantity,  well  diluted, 
may  be  given  by  the  rectum.  Its  hypodermic  use  is  infrequently 
resorted  to  chiefly  for  the  reason  that  other  remedies,  such  as  strych- 
nin and  digitalis,  are  more  effective  than  alcohol  when  so  given. 
The  doses  vary  from  five  drops  to  one-half  dram  every  one  or  two 
hours,  twelve  to  twenty-four  doses  in  twenty-four  hours,  for  a 
child  one  year  of  age.  A  child  two  years  of  age  may  be  given  one 
dram  at  intervals  of  one  or  two  hours.  Its  use  is  attended  with  the 
least  disturbance  when  it  is  given  after  the  feedings. 

HEAT  AS  A  THERAPEUTIC  AGENT 

Heat  has  long  been  used  as  a  therapeutic  measure.  In  infants 
and  children  it  has  a  wide  range  of  usefulness,  either  as  dry  heat  or 
by  the  use  of  water  as  a  vehicle. 

Moist  Heat. — Heat,  water-borne,  is  used  as  follows: 

In  colic  and  indigestion  and  as  a  diuretic,  internally. 

In  acute  gastritis,  as  a  sedative,  by  sipping  it. 

In  convulsions,  idiopathic  and  uremic,  by  means  of  baths. 

In  convulsions,  idiopathic  and  uremic,  as  colon  flushings,  105° 
to  iio°F. 

In  colic,  as  a  hot  stupe  applied  to  the  abdomen. 

In  torticollis,  as  a  hot  compress  to  the  neck. 

In  sprains,  as  a  hot  compress  to  the  joint  or  muscle. 

In  acute  ariicidar  rheumatism,  as  a  hot  compress  to  the  joint. 

In  retention  of  the  urine,  as  a  hot  compress  applied  to  the  lower 
abdomen  and  bladder. 

In  suppression  of  the  urine  {acute  nephritis),  as  a  poultice  or  hot 
compress  over  the  kidneys  and  in  colon  flushings,  105°  to  110°  F. 

In  cerebrospinal  meningitis,  as  a  hot  bath  or  hot  compress  to  the 
trunk  and  lower  extremities. 

In  pleurisy,  as  a  hot  compress  to  the  painful  area. 

In  acute  angina,  as  a  gargle. 

In  conjunctivitis,  as  a  hot  compress. 

To  hasten  suppuration  in  an  abscess,  as  a  poultice  or  compress. 


COLD   AS    A    TllERAI'IvUTlC    A(;ENT  499 

In  retropharyngeal  abscess  and  in  peritonsillitis  {quinsy),  as  a 
throat  douche. 

In  earache,  as  a  douche  or  by  means  of  a  hot-water  bag. 

In  toothache,  by  means  of  a  hot-water  bag,  or  as  hot  water  held 
in  the  mouth. 

In  facial  neuralgia,  by  means  of  a  hot-water  bag. 

In  prematurity,  and  in  lowered  vitality  or  reduced  temperature 
after  disease,  by  hot-water  bags  or  bottles. 

Dry  Heat. — Dry  heat  is  used  in  the  following  conditions: 

In  prematurity,  lowered  vitality,  or  reduced  temperature  after 
disease,  by  means  of  the  electrotherm  (page  46). 

In  suppression  of  the  urine  {acute  nephritis),  by  the  electro- 
therm,  or  by  hot  air  (page  346). 

In  using  heat  with  children  caution  should  be  exercised  as  to  the 
degree  employed.  Serious  burning  accidents  have  occurred  by  the 
use  of  hot-water  bottles  and  hot  compresses.  When  it  is  used  very 
hot,  the  hot-water  bottle  should  be  guarded  by  wrapping  it  in  flan- 
nel. Moist  heat  in  the  form  of  compresses,  poultices,  and  stupes 
should  always  be  tested  by  placing  the  vehicles  against  the  face  of 
the  attendant.  The  adult  hand  will  bear  a  greater  degree  of  heat 
than  is  safe,  oftentimes,  to  apply  to  the  skin  of  an  infant  or  young 
child.  In  using  hot  packs,  hot-water  bags,  the  electrotherm,  or 
dry  heat,  generated  by  a  lamp  or  other  device,  such  as  the  Kilmer 
kettle  (page  346),  a  thermometer  should  be  placed  between  the 
child's  clothing  and  the  bed-clothing.  A  temperature  of  110°  F.  is 
the  highest  to  use  with  children.  When  water  is  the  vehicle  it  must 
be  remembered  that  the  patient  must  be  most  carefully  watched 
and  the  application  frequently  renewed  because  of  the  rapid  evapo- 
ration. A  compress  or  poultice  must  not  be  allowed  to  get  cool.  A 
piece  of  flannel  or  oiled  silk  or  rubber  tissue  over  a  hot  compress  will 
obviate  the  necessity  for  frequent  changes. 

COLD  AS  A  THERAPEUTIC  AGENT 

In  the  treatment  of  children,  cold  is  generally  used  in  the  form 
of  compresses,  baths,  or  packs,  and  is  indicated  in  the  following  con- 
ditions : 

In  tonsillitis,  acute  pharyngitis ,  and  headache,  as  a  cold  compress. 

In  meningitis  and  pyrexia  by  means  of  the  ice-bag  or  the  cool 
coil. 

In  appendicitis  by  means  of  the  ice-bag. 

In  endocarditis  and  pericarditis  by  means  of  an  ice-bag. 

In  fever  by  means  of  baths,  cold  packs,  sponging,  and  in  older 
children  by  colon  flushings.     (Not  lower  than  70°  F.  when  used  thus.) 

In  adenitis  and  in  threatened  superficial  abscess  by  means  of  an 
ice-bag. 


500  THERAPEUTIC   MEASURES 

In  hysterical  and  neurotic  children  as  a  spinal  douche. 

In  malnutrition  in  older  children  as  a  tonic  by  means  of  a  mod- 
erate cool  spinal  douche  following  a  warm  bath. 

For  further  details  as  to  the  application  of  cold  for  special  dis- 
eases the  reader  is  referred  to  the  discussion  of  the  diseases  in  ques- 
tion. 

THE  THERAPEUTIC  VALUE  OF  CLIMATE 

That  climate  is  a  valuable  therapeutic  measure  in  the  treatment 
of  diseases  in  children  is  a  well  recognized  fact.  To  my  mind  an  im- 
portant advantage  of  a  change  of  climate  is  that  it  means  more  air 
and  better  air.  When  patients  go  to  a  resort  for  climatic  purposes 
it  is  usually  at  no  inconsiderable  expense,  and  they  are  therefore 
pretty  likely  to  avail  themselves  of  its  advantages.  The  same 
amount  of  air  oftentimes  could  be  furnished  at  home  if  the  family 
cooperation  always  could  be  secured.  By  the  use  of  the  window- 
board,  the  roof-garden,  and  the  indoor  airing,  we  can  to  a  consider- 
able degree  make  a  climate  of  our  own.  Nevertheless,  in  the  ma- 
jority of  families  the  open-air  treatment  cannot  be  carried  out  suc- 
cessfully; therefore  the  best  interests  of  the  patients  are  secured 
when  they  are  sent  away  from  home.  There  are  conditions  also  in 
which  such  means  as  those  just  mentioned  do  not  apply  even  if  they 
are  carried  out.  We  can  give  children  warm  air,  and  regulate  the 
temperature  of  the  air  in  the  winter;  but,  if  they  live  in  any  of  our 
coast  towns  or  villages,  we  cannot  give  them  cool,  dry  air  in  summer. 
Children  who  can  be  removed  from  a  large  city  to  the  country,  in- 
land, for  the  summer,  are  invariably  benefited,  not  only  as  regards 
their  food  capacity  and  the  ordinary  influences  of  open-air  life,  but 
they  acquire  also  greater  powers  of  resistance,  and  are  thus  less  liable 
to  attacks  from  acute  intestinal  diseases.  (See  Summer  Resorts, 
page  491.) 

During  the  colder  months  New  York  city  children  who  are  con- 
valescing from  pneumonia,  pertussis,  or  any  prolonged  illness  which 
has  greatly  reduced  them,  will  make  a  much  more  rapid  recovery 
when  removed  to  Lakewood  or  Atlantic  City,  where  open-air  life 
is  more  easily  secured  than  at  home.  Infants  and  children  suffering 
from  chronic  digestive  disorders,  marasmus,  and  malnutrition,  who 
are  given  the  advantages  of  climate  or  open-air  methods  either  in  the 
home  (page  147)  or  by  a  change  of  residence,  invariably  make  a  more 
rapid  recovery  than  do  those  deprived  of  it  because  of  a  lack  of  appre- 
ciation of  its  value,  or  through  fear  of  the  child's  taking  cold. 

Again,  there  are  diseases  in  children  in  which  the  sudden  change 
of  temperature,  affecting  the  peripheral  circulation,  may  be  decidedly 
harmful.  Such  conditions  exist  in  slow  convalescence  from  acute 
nephritis,  and  also  in  chronic  nephritis.  These  cases  require  an 
equable  climate,  with  a  permissible  outdoor  life  such  as  is  furnished 
during  our  colder  months  by  Florida  and  Lower  California. 


PROMISCUOUS  USE  OF  DRUGS  BY  THE  FAMILY         50I 

My  experiences  as  to  the  effects  of  climate  in  asthma  have  been 
contradictory.  As  a  rule,  cold  climates  and  high  altitudes  such  as 
are  offered  by  the  Adirondacks,  increase  the  asthma,  particularly  if 
emphysema  is  also  present.  Nevertheless,  I  have  seen  patients  who 
were  comfortable  only  when  living  under  such  climatic  conditions. 
From  November  ist  to  May  ist  the  best  results  have  been  effected 
in  children  by  a  change  of  residence  from  the  cold  and  changeable 
weather  of  the  Middle  and  Eastern  States  to  Lower  CaUfornia  or 
Florida.  Residence  at  the  seashore  has  not  been  helpful  to  my  pa- 
tients. Older  children  whose  parents  can  afford  it  should  be  sent  to 
a  boarding-school,  or  to  some  other  institution  of  learning  located 
where  the  climate  is  such  as  to  guarantee  freedom  from  attacks. 

The  best  winter  cUmate  for  a  child  with  pulmonary  tuberculosis 
is  a  dry  climate  with  a  mild  temperature,  neither  high  nor  low,  but 
with  sunshine  in  such  abundance  as  to  permit  a  daily  outdoor  Hfe. 
Such  a  cUmate  is  found  in  southern  New  Mexico  and  Arizona.  These 
places  furnish  conditions  as  near  to  the  ideal  as  it  is  possible  to 
approach.  The  Adirondacks,  while  furnishing  a  climate  in  winter 
which  may  be  too  severe  for  young  children,  answers  well  for  those 
from  eight  to  nine  years  of  age  in  w^hom  the  disease  is  not  far  ad- 
vanced. 

The  sanitarium  treatment  is  always  advised  if  the  patient  can 
afford  it.  Its  advantages  rest  in  the  fact  of  the  discipUne,  the  diet, 
the  amount  of  exercise,  the  sleeping  quarters,  the  clothing — in  short, 
in  all  the  details  of  life,  every  one  of  which  is  important.  In  a  sani- 
tarium all  these  matters  are  in  the  hands  of  those  who  are  skilled  in 
the  management  of  the  disease,  and  who  direct  each  case  according 
to  its  individual  needs.  Resorts  for  tuberculosis  cases  are  dangerous 
because  of  the  possibilities  of  reinfection  through  the  carelessness  of 
others.  In  a  well-managed  sanitarium,  however,  regulations  regard- 
ing expectoration  and  the  care  of  the  sputum  reduce  this  danger  to  a 
minimum.  Sanitariums,  however,  are  available  to  but  few  patients. 
Many  have  not  the  means  necessary  to  a  change  of  residence,  and 
many  others  refuse  to  allow  their  children  to  be  separated  from 
them,  both  of  which  facts  necessitate  the  home  treatment  of  a  great 
majority  of  the  cases  of  pulmonary  tuberculosis  in  young  children  in 
our  larger  cities.     (See  page  287.) 

PROMISCUOUS  USE  OF  DRUGS  BY  THE  FAMILY 
While  the  giving  of  drugs  to  children  by  members  of  the  family 
is  not  to  be  encouraged,  I  find  it  wise  to  furnish  to  most  mothers  a 
list  of  "permissibles."  The  love  of  people  all  the  world  over  for 
drugs  and  their  faith  in  their  efffcacy  is  so  great  that  if  they  are  not 
supplied  by  the  physician,  they  are  very  apt  to  secure  them  elsewhere. 
If  the  reader  has  had  an  opportunity  to  look  through  the  closets  or 
chests  of  his  patients,  where  medicines  are  kept,  he  perhaps  has  been 


502  THERAPEUTIC   MEASURES 

surprised  at  the  number  of  preparations  of  proprietary  and  patent 
medicines  which  met  his  gaze.  The  solution  of  the  so-called  "nos- 
trum evil"  would  be  very  simple  if  every  physician  would  take  the 
trouble  to  explain  to  his  patients  the  character  of — or,  better,  send 
them  a  copy  of  the  official  analyses  of — the  various  proprietary  drug 
preparations  on  the  market.  They  should  be  convinced  not  only 
of  their  worthlessness,  but  also  of  the  dangers  attending  their  use. 
If  mothers  knew  that  most  cough  syrups  and  colic  cures  contain  opium 
or  some  of  its  derivatives,  they  w^ould  not  give  them  to  their  children. 
Neither  would  they  themselves  take  the  various  tonics  and  restora- 
tives, "discoveries,"  and  "bitters"  in  the  market  if  they  knew  that 
they  contained  a  large  percentage  of  alcohol.  It  is  the  duty  of  phy- 
sicians to  counteract,  by  teaching,  the  influence  of  the  ingeniously 
constructed  medical  advertisements  in  the  daily  and  weekly  press, 
in  both  religious  and  lay  periodicals.  Not  a  little  of  what  passes  for 
knowledge  of  diseases  and  their  so-called  treatment  is  thus  obtained 
by  the  layman  through  means  that  are  intentionally  misleading.  It 
has  long  been  my  custom  to  give  the  mother  prescriptions  for  coughs, 
for  head  colds,  and  for  constipation.  They  are  prepared  and  kept 
on  hand  for  use  in  case  they  are  required.  At  the  same  time  the 
mother  understands  that  I  am  to  be  called  at  once  as  soon  as  the 
child  has  fever.  In  defense  of  this  practice,  which  may  be  open  to 
criticism,  I  would  state  that  I  prefer  to  have  my  young  patients  take 
the  remedies  I  prescribe,  and  which  are  harmless,  rather  than  to  have 
them  run  the  risk  of  the  administration  of  opium  and  alcohol,  which 
would  be  very  apt  to  be  the  case  if  this  precaution  were  not  taken. 

UNPALATABLE  AND  NAUSEATING  DRUGS 
It  is  impossible  to  mention  in  detail  all  the  drugs  which  might  be 
included  under  this  heading.  Only  those  w411  be  referred  to  which 
we  are  obliged  to  use  almost  daily  in  our  work — drugs  which  are 
either  unpleasant  to  the  taste  or  which  may  be  badly  borne  by  the 
stomach  or  drugs  combining  both  these  elements.  How  to  admin- 
ister certain  drugs  so  that  their  use  may  be  continued  and  yet  not 
interfere  with  the  digestive  function,  is  a  question  which  deeply  con- 
cerns those  who  may  have  children  for  their  patients.  The  element 
of  taste  is  a  most  important  one  in  a  child;  therefore,  when  possible, 
drugs  disagreeable  to  the  taste  should  be  given  to  children  in  tablet 
or  pill  form  or  in  capsule.  The  continued  use  of  a  drug  oftentimes 
depends  upon  its  being  made  palatable.  As  a  general  rule,  when 
pills,  tablets,  or  capsules  are  given,  one-half  glass  of  water  should  be 
taken  at  the  same  time,  in  order  to  diminish  any  possible  irritant 
effects  upon  the  mucous  membrane  of  the  stomach. 

Salicylate  of  Soda. — Salicylate  of  soda  is  a  drug  disagreeable  in 
taste  and  very  liable  to  destroy  the  appetite  and  interfere  with  di- 
gestion.    In  acute   rheumatism  its  use  is  invaluable,   and  we  are 


UNPALATABLE  AND  NAUSEATING  DRUGS  503 

obliged  oftentimes  to  give  it  in  large  doses.  It  is  best  given  after 
meals  with  one-half  glass  of  milk.  It  is  better  to  give  fairly  large 
doses  at  this  time,  well  diluted,  rather  than  more  frequent  smaller 
doses.  It  usually  is  better  borne  if  given  in  solution  with  pepper- 
mint-water or  with  simple  elixir  diluted  50  percent  with  water;  but 
the  taste  when  thus  given  is  only  partially  disguised,  and  being  still 
very  objectionable  to  many,  it  may  be  given  in  capsule  if  the  patient 
is  old  enough,  care  being  taken  to  give  a  considerable  amount  of  water 
or  milk  with  each  capsule, 

lodid  of  Potash. — This  drug  is  indispensable  and  is  one  for  which 
no  other  can  be  substituted.  It  is  best  given  in  solution.  It  is  most 
disagreeable  in  taste  and  a  direct  irritant  to  the  mucous  membrane 
of  the  stomach.  Like  salicylate  of  soda,  it  should  be  given  after 
meals  with  from  one-half  to  one  glass  of  water  or  milk.  It  is  best 
given  plain,  using  the  saturated  solution,  which  may  be  dropped  into 
the  milk. 

Bichlorid  of  Mercury. — This  drug  is  usually  given  in  such  small 
doses  that  its  irritant  properties  are  but  little  felt.  It  is  best  pre- 
scribed in  tablet  form,  dissolved  in  two  teaspoonfuls  of  water  and 
followed  by  a  swallow  of  water.  When  possible,  it  should  be  given 
after  feeding. 

Alcohol. — Alcohol  is  another  drug  which  should  be  given  well  di- 
luted, regardless  of  the  form  in  which  it  is  administered.  It  is  best 
given  with  or  after  food,  but  it  should  always  be  given  diluted  with 
at  least  six  parts  of  water,  if  whisky  or  brandy  is  used. 

Ipecac  and  Tartar  Emetic. — Ipecac  and  tartar  emetic,  when  em- 
ployed as  expectorants,  are  best  given  with  sugar  of  milk  in  powder 
or  tablet  form.  They  should  never  be  given  on  an  empty  stomach. 
Two  or  three  teaspoonfuls  of  water  should  precede  their  adminis- 
tration when  they  are  not  given  within  a  reasonable  time  after 
feeding.  In  many  children,  when  given  without  this  precaution 
even  in  the  usual  doses,  they  will  often  decrease  the  appetite  and  the 
digestive  capacity. 

The  Ammonium  Salts. — Carbonate  of  ammonia  must  always  be 
given  in  solution  and  should  always  be  well  diluted  with  water.  Mu- 
riate of  ammonia  may  be  used  in  tablet  or  powder  form.  Water  or 
milk  should  precede  the  administration  of  either.  One  part  of 
simple  elixir  with  two  parts  of  water  make  an  agreeable  combination. 

Oils. — Oils  used  for  nutritive  purposes  should  invariably  be  given 
after  meals.  Plain  cod-liver  oil  or  any  of  the  preparations  contain- 
ing it  should  never  be  given  on  an  empty  stomach. 

Castor  Oil. — Castor  oil  is  best  given  when  the  stomach  is  empty. 
A  much  more  prompt  and  satisfactory  cathartic  effect  is  produced 
when  thus  given.  It  may  be  given  in  soda-water  or  coffee,  with 
orange-juice  or  in  peppermint-water.  Older  children  sometimes 
take  it  better  plain,  sandwiched  between  the  two  halves  of  a  pep- 


504  THERAPEUTIC   MEASURES 

permint  cream,  first  the  candy,  then  the  oil,  followed  by  the  remain- 
der of  the  candy.  If  castor  oil  is  vomited,  it  may  be  repeated  in  a 
few  minutes,  and  often  will  then  be  retained. 

Creosote. — Creosote  is  most  difficult  of  administration  to  many 
children,  I  usually  prescribe  the  carbonate,  which  is  ordered  to  be 
dropped  into  one  or  two  teaspoonfuls  of  wine  after  meals.  It  may 
also  be  given  in  soft  capsules,  or  in  an  emulsion, 

Quinin. — Quinin  should  be  given  in  solution  or  in  capsule,  Quinin 
pills  as  they  are  sometimes  made,  with  an  insoluble  coating,  pass  un- 
changed through  the  entire  intestinal  canal.  When  given  in  solu- 
tion, a  most  satisfactory  menstruum  is  a  preparation  of  yerba  santa, 
known  to  the  trade  as  yerberzine  (Lilly),  The  bisulphate  should 
always  be  prescribed  for  children,  for  the  reason  that  it  may  be  given 
in  complete  solution  without  the  addition  of  acid. 

Strychnin. — Strychnin  on  account  of  its  taste  is  often  strenuously 
objected  to,  and  is  therefore  better  given  in  tablet  triturate  form. 
If  the  tablet  cannot  be  swallowed,  it  may  be  broken  into  small  pieces 
(not  powdered)  and  mixed  with  a  teaspoonful  of  orange  pulp  or  in  a 
thick  cereal  jelly. 

Digitalis, — Digitalis,  when  the  tincture  or  the  infusion  is  used, 
should  never  be  given  when  the  stomach  is  empty.  It  should  be  ad- 
ministered either  after  meals  or  follow  the  drinking  of  water  or 
milk.  There  are  few  drugs  that  will  so  completely  destroy  a  child's 
desire  for  food  as  the  digitalis  preparations  when  put  into  an  empty 
stomach. 

Tincture  of  Muriate  of  Iron. — The  tincture  of  muriate  of  iron 
should  be  given  well  diluted  after  meals  in  at  least  one-half  glass  of 
water.  The  child  should  take  it  through  a  glass  tube  so  as  not  to 
injure  the  teeth.  In  the  use  of  the  iron  preparations  generally,  they 
should  be  given  after  meals,  and  in  case  the  hquid  preparations  are 
used,  thev  should  be  well  diluted  with  water. 


GYMNASTIC  THERAPEUTICS 

The  section  on  Gymnastic  Therapeutics  is  included  in  order  to 
call  the  attention  of  general  practitioners  to  the  value  of  such  work 
and  to  assist  them  in  applying  necessary  treatment.  Exercises  are 
most  often  used  therapeutically  for  children  in  the  treatment  of  the 
following  conditions:  Flattened  or  narrowed  thorax,  kyphosis, 
scoHosis,  flat-foot,  congenital  ataxias,  and  acute  anterior  polio- 
myelitis;  also  in  cases  of  habitual  constipation,  malnutrition,  etc. 

The  following  pages  contain  a  description  of  the  methods  which 
have  been  carried  out  most  successfully  with  my  patients  by  Dr. 
Hugh  Currie  Thompson,  New  Rochelle,  N.  Y.,  to  whose  patience  and 
skill  I  am  indebted  for  the  recovery  of  many  cases,  some  of  which 
had  resisted  other  methods  of  treatment. 

The  family  physician  has  an  opportunity  of  seeing  these  con- 
ditions at  a  much  earlier  stage  than  has  the  specialist,  and  at  a 
time  when  they  may  be  more  easily  corrected  than  in  later  life. 
When  discovered,  such  conditions  should  never  be  neglected  with 
the  idea  that  in  time  the  child  will  outgrow  them.  Such  a  beHef 
is  often  fallacious,  for  unless  properly  treated,  they  are  apt  to  become 
permanent.  The  necessity  for  the  correction  of  physical  defects 
in  children  is  readily  appreciated  by  parents.  Certain  principles 
or  rules  are  involved  in  every  form  of  practice.  The  following 
principles  are  generally  applicable  in  gymnastic  therapeutics. 

RULES 

I.  Examination. — As  far  as  possible,  obtain  a  complete  history 
of  the  case.  Make  both  a  general  and  a  careful  phvsical  examina- 
tion; under  the  latter,  note  the  musculature,  condition  of  the  skin, 
posture,  any  deviation  of  the  spine,  position  of  thorax  and  scapulae, 
side  lines  of  body,  compare  length  of  Hmbs,  note  the  condition  of 
the  feet.  It  is  often  advantageous  to  take  the  height  and  weight, 
and  certain  measurements,  such  as  girth  of  neck,  chest,  and  waist, 
and  depth  of  chest  and  abdomen.  In  cases  where  the  nervous 
system  is  especially  involved  apply  the  tests  usually  made  in  such 
cases. 

II.  Conditions  under  "Which  Exercise  Should  be  Taken. — (a) 
Temperature  of  Exercise-room. — The  temperature  of  the  room  should 
be  from  70°  to  75°  F.  and  there  should  be  no  draft  upon  the  patient. 
Therapeutic  gymnastics  involves  fewer  groups  of  muscles  than  ordi- 
nary gymnastic  work  and  the  execution  is  slower.     The  general 

505 


5o6  GYMNASTIC    THERAPEUTICS 

circulation  and  respiration  are  not   stimulated  as  much  and  there- 
fore the  heat  production  is  less. 

(b)  Clothing. — In  the  beginning,  the  parts  of  the  body  involved 
in  the  exercises  should  be  devoid  of  clothing.  A  single  thickness 
of  clothing  may  mislead  as  to  the  corrective  effect  obtained.  At 
frequent  intervals,  at  least  once  a  week,  the  child  should  be  uncovered 
for  the  purpose  of  observation  during  exercises.  It  is  sometimes 
desirable  to  have  the  clothing  removed  during  each  treatment. 
At  all  times  a  child's  clothing  should  be  simple  and  hygienic,  per- 
mitting unhampered  movements. 

(c)  Double  Mirrors,  etc.- — The  use  of  double  mirrors  and  a  stringed 
screen  are  sometimes  desirable  so  that  the  child  may  see  when  he 
has  a  correct  position. 

III.  Frequency  and  Duration  of  Treatments. — Treatment  should 
be  for  an  hour  daily,  Sundays  and  holidays  excepted.  This  is  not 
too  often,  if  the  following  points  are  considered : 

(a)  The  length  of  time  during  which  the  condition  has  been 
developing. 

(b)  The  number  of  waking  hours  intervening  between  treat- 
ments when  faulty  postures  are  apt  to  be  maintained. 

(c)  That  progress  should  be  made  as  rapidly  as  possible,  so  that 
the  changed  structure  may  be  the  basis  for  the  period  of  growth. 

Many  times  this  rule  must  be  modified,  owing  to  the  physician's 
lack  of  time  and  the  expense  to  the  patient's  family.  From  an 
hour's  supervision  daily  it  may  mean  supervision  by  the  physician 
only  once  every  two  weeks,  supplemented  by  careful  home  super- 
vision fifteen  minutes  daily.  This  arrangement  should  be  the  mini- 
mum of  attention  given  to  anv  case. 

IV.  Prescription  of  Exercises. — (a)  Forms  of  Exercise. — No  cer- 
tain system  of  exercises  need  be  followed  as  long  as  the  exercises 
used  have  an  anatomic  and  physiologic  basis.  Both  active  and 
passive  movements  are  used  with  and  without  resistance.  Exer- 
cises with  resistance  given  by  the  physician  are  used  much  in  cor- 
rective work,  for  in  this  form  of  exercise  the  physician  can  easily 
judge  as  to  the  amount  of  exertion  and  increase  or  decrease  it  at 
will. 

(b)  Accuracy  of  Execution. — Accuracy  of  execution  of  each  and 
every  exercise  given  in  the  prescription  is  essential.  A  possible 
exception  to  this  might  occur  in  the  treatment  of  such  cases  as  mal- 
nutrition or  constipation,  where  exercise  per  se  is  the  essential  thing, 
but  even  in  these  cases  conditions  may  be  such  that  very  careful 
work  is  necessary.  A  prescription  of  exercise  in  itself  means  little. 
The  manner  in  which  it  is  executed  may  actually  aggravate  the 
condition,  as  the  wrong  muscles  may  be  made  stronger  by  a  faulty 
manner  of  execution.  In  writing  out  a  prescription  of  exercise  the 
physician  should  be  guided  by  the  patient's  capability  for  fairly 


RULES  507 

accurate  execution  of  each  exercise.  This  cannot  be  gaged  by  the 
physical  examination  alone,  but  the  examination  must  be  supple- 
mented by  having  the  patient  try  the  exercise  for  one  or  more  days. 
Unless  he  can  approximate  the  proper  execution  without  assuming 
faulty  positions  or  postures  and  without  causing  too  much  nerve  and 
muscle  fatigue,  simpler  exercises  should  be  used.  As  the  patient  im- 
proves or  becomes  stronger,  more  difficult  exercises  should  be  given. 
In  advancing,  the  rule  regarding  accuracy  should  be  observed. 

Exercises  have  several  details  which  need  to  be  watched  in  order 
to  secure  accurate  execution.  At  first  do  not  confuse  the  child 
by  requiring  absolute  accuracy  as  to  every  detail;  rather  select  one 
or  two  of  the  more  important  ones  and  insist  upon  the  most  rigid 
observance  of  these.  As  the  child  grasps  and  retains  these  ideas 
and  is  able  to  carry  them  out,  require  more,  until  all  are  mastered. 

(d)  Concentration. — Frequent  repetition  of  the  exercises  is  nec- 
essary to  obtain  desired  results.  In  repeating  an  exercise  many 
times,  a  child  easily  forms  the  habit  of  executing  it  with  but  little 
effort,  which  will  soon  result  in  inattention  and  carelessness.  When 
this  occurs  bring  about  an  increase  of  exertion  on  his  part  bv  insist- 
ing that  every  detail  be  mastered,  or  change  to  more  difficult  exer- 
cises. 

(e)  Ovenvork. — If  a  child  is  fatigued  at  the  end  of  an  hour's 
rest  following  the  treatment,  he  has  been  overworked,  and  the  exer- 
cises should  be  made  less  difficult.  A  certain  amount  of  muscle 
soreness  must  be  expected  during  the  first  few  davs  of  work. 

(/)  Rest. — In  many  cases  the  child  should  rest  in  a  recumbent 
posture  for  half  an  hour  after  the  treatment,  and  in  nervous  cases 
the  treatment  should  be  preceded  by  a  half  hour's  rest. 

(g)  General  Health. — Attention  should  be  given  to  everything 
that  will  build  up  the  general  health  of  the  patient,  such  as  bathing, 
sleep,  fresh  air,  general  exercise,  diet,  dress;  suitable  furniture  (chairs, 
tables,  or  desks,  etc.)  should  also  be  considered.  Attention  to  these 
things  will  sometimes  shorten  the  time  of  treatment  by  eUminating 
causative  factors. 

V.  Adaptation  of  Exercise  to  Practical  Ends. — Adapt  corrective 
positions  to  all  practical  ends:   walking,  sitting,  working,  or  playing. 

VI.  Cooperation. — Endeavor  to  secure  the  cooperation  of  mem- 
bers of  the  household,  teachers  or  servants,  between  exercise  periods 
in  order  that  the  progress  of  the  child  may  be  as  rapid  as  possible. 
A  child  is  not  at  first  capable  of  adapting  the  work  to  practical  ends 
without  careful  oversight  of  elders. 

VII.  Period  of  Treatment. — There  are  two  objects  in  treatment: 
One  which  should  always  be  obtained,  that  of  improvement;  and 
the  other  complete  and  permanent  correction,  which  should  be  the 
aim  until  an  insurmountable  obstacle  is  reached.  To  gain  these  are 
required,  continuous  and  conscientious  work,  and  the  cooperation  of 


5o8 


GYMNASTIC   THERAPEUTICS 


those  in  charge  of  the  child  and  of  the  child  himself.     As  a  rule, 
these  objects  cannot  be  obtained  in  a  short  period  of  time. 

After   the   treatment  has  been  completed  the  child  should  be 
brought  for  examination  every  three  months. 


POSTURE  AND  BREATHING 
Posture  and  breathing  will  first  be  considered,  as  they  hold  an 

important  place  in  the  correction  of  the  conditions  about  to  be  con- 
sidered. A  good  posture  should  be  maintained 
during  all  exercises.  Between  treatments  the 
child  should  maintain  as  good  posture  as  his 
condition  will  permit.  TelHng  him  to  do  this 
is  not  sufficient,  but  he  should  be  given  exer- 
cises which  will  strengthen  the  weakened  and 
overstretched  muscles  and  stretch  the  con- 
tracted ones,  and  thus  enable  him  to  assume 
an  improved  posture.  The  work  for  correct- 
ing posture  should  be  taken  up  gradually. 
Have  a  child  hold  a  good  posture  for  short 
periods  of  time,  beginning  with  one  minute 
and  working  up  to  fifteen  minutes.  The  child 
should  be  taught  to  assume  and  maintain  a 
good  posture  during  the  entire  day,  no  matter 
what  he  is  doing,  whether  at  work  or  play. 
In  the  standing  posture  the  weight  of  the 
body  should  be  brought  forward  until  it  rests 
over  the  balls  of  the  feet  or  over  a  point  mid- 
way between  the  toes  and  the  heels.  In  sit- 
ting, the  weight  of  the  body  should  be  carried 
over  the  posterior  third  of  the  thighs. 

For  general  posture,  my  rule  consists  of 
the  following  steps:  Heels  together,  or  ap- 
proximately so,  knees  well  stretched;  chest 
raised  high ;  head  erect  with  chin  in  (stretch 
up  entire  body  as  high  as  possible) ;  poise 
weight  forward  over  balls  of  feet;  bring 
shoulders  back  and  down.  The  feet  should  be 
turned  outward  slightly  or  kept  straight. 
(See  Fig.  55.) 

In  the  above  rule  do  not  relax  any  pre- 
00.   v^j^^.^n,^«..    xw=,.-     vious  step  as  a  new  one  is  taken.     In  sitting, 
insist  that  the  hips  be  pushed  well  back  in  order 

that  the  child  may  not  slide  forward  so  as  to  bring  the  weight  of  the 

body  over  the  lower  spine. 

From  the  beginning,  an  attempt  should  be  made  to  improve  the 

posture.     Take  the  essential  details  for  the  child  to  follow  and  in- 


POSTURE    AND    BREATHING  509 

crease  the  requirements  as  fast  as  practicable.  These  individual 
details  have  been  tersely  expressed  in  different  ways,  and  one  ex- 
pression may  convey  the  idea  of  the  detail  more  clearly  to  one  patient 
and  another  expression  to  another.  For  instance:  "Chest  Up!" 
may  mean  that  you  wish  the  child,  if  he  has  relaxed,  to  take  the 
best  possible  posture  of  the  thorax.  In  taking  a  good  position  of 
the  thorax,  there  should  be  no  raising  of  the  shoulders,  no  conscious 
taking  in  or  holding  of  the  breath,  and  the  trunk  should  not  be 
inclined  backward  nor  the  pelvis  or  abdomen  permitted  to  project 
forward. 

General  Considerations. —  i.  When  children  use  bicycles,  veloci- 
pedes, mail  wagons,  etc.,  where  they  propel  themselves  by  pedal- 
ing, they  should  not  ride  with  head  and  shoulders  forward  and  chest 
contracted  to  gain  advantage  and  leverage,  but  should  have  the 
body  inclined  forward  from  the  hips,  back  straight,  and  chest  ex- 
panded. 

2.  Improper  and  insufficient  diet,  poor  assimilation,  lack  of  fresh 
air,  and  disturbed  sleep  cause  a  loss  of  general  tone,  which  tends  to 
make  a  child  relax  and  assume  bad  postures.  All  these  matters 
should  receive  attention.     See  Tardy  Malnutrition,  page  158. 

3.  Cloihing  should  be  examined  to  see  that  it  causes  no  pressure 
or  tension.  All  garments  should  be  loose  and  simple.  The 
underclothing  should  be  elastic  and  light  in  weight.  The  stock- 
ings should  fit  the  feet  and  should  be  supported  by  soft  elastics 
extending  from  V-shaped  pieces  at  the  side  of  the  waist,  which  catch 
the  stockings  on  the  outside  of  the  legs.  The  shoes  should  have 
flexible  soles,  a  fairly  straight  line  on  the  inside,  a  low  broad  heel, 
and  should  be  broad  enough  to  permit  the  toes  to  spread.  So 
much  depends  upon  the  condition  of  the  feet,  both  in  standing  and 
walking,  that  they  should  receive  as  careful  daily  attention  as  the 
hands.  Hats  should  first  be  for  protection.  They  should  be  light 
in  weight  and  should  come  far  enough  forward  to  protect  the  eyes 
from  the  sun,  and  should  never  be  worn  far  enough  back  to  make 
the  child  tilt  his  head  to  balance  the  weight,  or  to  make  him  bend 
it  forward  to  protect  his  eyes  from  the  sun.  Outside  wraps  should 
be  sufficiently  light  in  weight  and  flexible  enough  to  permit  free 
movement  in  walking  or  running. 

4.  Sleep. — A  child  should  not  form  the  habit  of  sleeping  always 
on  one  side  with  the  knees  drawn  up  to  the  chest,  but  change  from 
side  to  side.  If  the  posture  is  very  poor,  he  should  for  some  time 
sleep  on  the  back  with  limbs  extended,  and  without  a  pillow.  The 
mattress  should  be  thin  and  firm,  and  the  child's  covering  light  in 
weight,  and  only  a  small  pillow  used. 

5.  FurnUure. — The  furniture  a  child  uses,  especially  his  chairs, 
tables,  or  desks,  should  be  adapted  to  his  age  and  height.  Furniture 
not  properly  adapted  to  children  is  one  of  the  main  causes  of  bad 


5IO 


GYMNASTIC    THERAPEUTICS 


posture.  Chairs  should  have  the  height  of  seat  correspond  to  the 
length  of  the  lower  leg.  The  child's  feet  should  rest  comfortably 
upon  the  floor,  and  there  should  be  no  pressure  under  the  knee. 
The  depth  of  the  seat  should  be  no  more  than  the  length  of  the 
thigh.  If  it  is  greater  the  child  tends  to  sUde  forward,  and  assume 
a  bad  posture  with  the  weight  of  the  trunk  over  the  lower  spine. 
The  back  of  a  chair  should  not  have  upright  spindles,  but  cross- 
pieces,  or,  at  least,  one  cross-piece  sufficiently  high  above  the  seat 
to  allow  the  fleshy  part  of  the  hips  to  project  underneath  it  in  order 
to  bring  back  the  tuberosities  of  the  ischii  far  enough  to  support  the 
weight  of  the  trunk  in  a  good  position.  The  lower  cross-bar,  pre- 
ferably adjustable,  should  support  the  back  at  the  junction  of  the 


Adjustable  Table,   Dr.   Mosher's  Chairs,   Board,  Ladder,   and  Blocks  for 
Ataxic  Exercises. 


dorsal  and  lumbar  vertebrae.     In  addition  there  should  be  another 
cross-bar  to  support  the  upper  back. 

Dr.  Mosher's  kindergarten  chair,  sold  by  The  Milton  Bradley 
Company,  ii  East  i6th  Street,  New  York  city,  is  the  best  chair 
for  children  that  has  come  to  my  attention.  It  is  constructed  in 
three  sizes,  with  seats  ten,  twelve,  or  fourteen  inches  in  height,  but 
there  is  no  lower  cross-bar  for  the  support  of  the  back.  If  the 
seat  of  a  chair  is  hollowed  out.  there  should  be  no  raised  border  at 
the  back,  as  it  would  prevent  the  hips  from  being  pushed  well  back. 
If  well-constructed  chairs  cannot  be  obtained,  ordinary  chairs  may 
be  modified  for  use  in  the  nursery  or  for  older  children,  by  selecting 
those  having  a  cross-bar  several  inches  from  the  seat  and  sawing 


POSTURE    AND    BREATHING 


511 


the  legs  off.  If  the  scat  proves  too  deep,  a  pillow  may  be  placed 
between  the  child's  back  and  the  back  of  the  chair,  but  it  should  not 
extend  below  the  waist-line. 

6.  Heredity.— Parents  often  attribute  a  bad  posture  with  flat 
chests  or  other  physical  deformities  to  heredity,  saying  that  a 
child  "takes  after"  one  parent  or  the  other.  Heredity  is  usually 
only  a  shght  factor,  i.  e.,  the  child  may  inherit  a  frame  or  general 
constitution   or  certain 

mental  and  physical 
characteristics  resem- 
bling those  of  a  parent, 
but  the  faulty  posture, 
flat  chest,  etc.,  are  in 
most,  if  not  all,  cases 
acquired.  A  well-nour- 
ished infant  has  a 
straight  back.  In  a 
well  child,  you  seldom 
see  a  flat  chest  before 
the  age  of  three  years. 

7.  In  very  young 
children,  the  deformity 
is  often  induced  by  the 
position  assumed  in 
play.  For  instance,  the 
sitting  position  on  floor 
or  bed  with  legs  ex- 
tended and  spine  bent 
forward,  which  most 
young  children  assume 
in  playing,  keeps  the 
chest  in  a  bad  position 
for  long  periods  of  time 
day  after  day.  This  is 
especially  true  if,  for 
any  reason,  the  back 
muscles  are  not  as 
strong  as  usual  and  can- 
not easilv  maintain  the 
weight  of  the  trunk  in 
an  erect  position.     For 

children  who  are  kept  in  bed  when  not  seriously  ill,  a  folded  blanket 
or  air-cushion  may  be  used  as  a  seat,  and  a  bed  table  or  tray,  for 
playthings  and  meals.     A  support  may  be  used  for  the  back  if  needed. 

Fig.  56  shows  Dr.  Mosher's  chair  and  an  adjustable  table, 
may  be  made  for  use  in  the  nursery, 


Chest  raising  agai 


which 
The  top  of  the  table,  2^  by 


512 


GYMNASTIC    THERAPEUTICS 


4  feet  (or  3  by  5),  is  made  of  well-seasoned  boards  h  inch  in  thick- 
ness. These  boards  are  held  together  by  quarter-inch  pegs  and 
holes,  as  are  the  leaves  of  an  extension  dining-table.  Two  sets  of 
light-weight  wooden  horses  (legs  f  by  2  inches  and  cross-pieces  i 
by  2^^  inches)  are  used  for  supports:  one  set,  for  use  when  the  child 
is  seated,  14  to  18  inches  in  height;  the  other,  for  use  when  standing, 
24  to  30  inches  in  height.  If  desired,  the  whole  may  be  painted 
white  or  stained  and  varnished.  For  reading  there  should  be  a 
book-support  for  the  child's  books,  so  that  he  may  keep  his  head 
erect. 

8.  School  Hygiene. — Physicians  as  well  as  parents  should  interest 
themselves  in  school  conditions,  as  often  it  is  in  school  that  the  child 


Fig.  58.— Posture  Exercise. 
Arching  body. 

contracts  bad  postures,  because  of  the  long  hours  of  confinement, 
unsuitable  desks  and  seats,  and  frequently  by  a  lack  of  proper 
ventilation. 

Exercises. — The  following  exercises  may  be  used  for  correcting 
postures. 

1.  The  child  stands  with  toes  from  2  to  4  inches  from  a  flat  per- 
pendicular surface,  as  a  closed  door.  Tet  him  assume  a  good  stand- 
ing position ;  sway  the  body  forward  from  the  heels  (heels  kept  on 
floor)  until  the  chest  touches  the  door;  but  neither  the  abdomen 
nor  head  should  touch  it.     (See  Fig.   57.) 

2.  Raise  arms  sideways  to  shoulder  height;  lift  heels;  stretch 
up  with  head  and  chest,  in  with  chin,  and  out  with  arms. 


BREATHING  513 

3.  The  child  Ues  on  his  back  on  a  fairly  hard,  flat  surface.  Place 
your  hands  under  his  head,  raising  it  an  inch  or  two.  lie  then, 
reclining  as  before,  arches  his  body  from  head  to  heels.  (See  Fig. 
58.)  The  knees  should  be  kept  straight.  In  the  beginning,  as 
in  figure,  he  may  aid  himself  with  his  hands  in  arching  body. 
Later  the  arms  should  be  folded  lightly  on  the  chest. 

4.  The  child  standing,  should  raise  arms  sideways,  turn  palms 
up  at  shoulder-height,  and  continue  to  raise  them  until  the  hands 
are  midway  between  horizontal  and  vertical;  sway  bodv  forward; 
stretch  up  with  chest  and  head,  in  with  chin,  and  out  and  up  with 
finger-tips. 

5.  Clasp  hands,  back  of  head.  Raise  chest  well  and  press  head 
backward,  chin  in,  resisting  with  hands.     Keep  elbows  well  back. 

Walking  Movcmenis. — Have  patient  walk  on  balls  of  feet,  with  arms 
extended  sideways,  shoulder  high,  maintaining  a  good  posture.  When 
capable  of  doing  this  satisfactorily,  repeat  with  arms  raised  over 
head;  arms  should  be  well  stretched,  fingers  straight,  palms  facing 
and  separated  by  the  breadth  of  the  shoulders. 

BREATHING 

The  primary  object  of  breathing  is  to  aerate  the  blood  by  carry- 
ing oxygen  to  it  by  the  air  that  enters  the  lungs;  secondarily,  through 
the  practice  of  deep  breathing,  the  accessory  muscles  of  respiration  are 
developed,  the  breadth  and  depth  of  chest  and  the  lung  capacity 
are  increased.  In  deep  respiration  the  amount  of  air  taken  in 
is  several  times  that  inhaled  in  ordinary  respiration.  The  amount 
inhaled  in  "tidal"  respiration  by  an  adult  is  30  cubic  inches,  while 
that  which  can  be  taken  in  by  forced  inspiration  is  from  150  to  300 
cubic  inches.  Daily  practice  of  deep  breathing  in  the  open  air 
helps  to  increase  the  resistance  of  the  lungs  to  diseases  to  which  they 
are  liable. 

A  mistake  is  sometimes  made  in  overdeveloping  the  chest  mus- 
cles, so  that  the  chest  becomes  to  a  certain  extent  "muscle-bound," 
and  the  expansion  is  lessened,  instead  of  increased.  There  is  little 
danger  of  this  when  the  development  comes  from  taking  deep  inspira- 
tions rather  than  by  muscular  activity  alone.  While  a  development 
of  the  chest  muscles  is  desirable,  they  should  not  be  developed  at  the 
expense  of  the  normal  expansion  of  the  "respiratory  chest."  The 
aim  should  be  to  improve  the  molnlity  of  the  chest  and  the  lung 
capacity  as  well  as  to  strengthen  the  muscles. 

Two  kinds  of  breathing  are  usuallv  spoken  of:  ihoracic  and  ah- 
dominal.  Breathing  should  be  considered  as  a  whole,  unless  one 
form  is  especially  lacking,  as,  for  instance,  where  a  child  has  a  very 
flat  chest  in  which  diaphragmatic  or  abdominal  breathing  greatly 
predominates  over  the  thoracic,  and  there  is  little  mobility  in  the 
upper  part  of  the  chest.  If  the  abdominal  breathing  needs  to  be 
33 


514  GYMNASTIC  THERAPEUTICS 

developed,  have  the  child  stand  in  a  good  posture,  with  hands  placed 
lightly  over  the  lower  ribs,  with  tips  of  the  fingers  two  or  three  inches 
from  the  median  line,  and  take  long,  deep  breaths  until  he  secures  a 
good  movement  of  the  lower  ribs.  The  hands  are  placed  over  the 
ribs,  only  for  the  purpose  of  feeling  the  movement. 

All  breathing  exercises  should  be  taken  with  the  body  in  a  good 
position  and  may  be  done  while  standing,  lying,  sitting,  or  slowly 
walking.  Ordinarily  they  are  taken  in  a  standing  position.  If 
the  muscles  are  weak  or  if  it  is  difficult  to  stand  in  a  good  position, 
they  may  be  taken  in  a  sitting  or  reclining  position.  When  the 
breathing  exercise  is  taken  reclining,  a  couch  or  a  board  resting  on 
two  chairs  may  be  used  in  preference  to  a  bed  or  the  floor.  A  small 
hard  pillow  or  a  folded  bath-towel  may  be  placed  under  the  shoulders 
and  upper  back,  but  should  not  extend  under  the  head.  Snch  a  pad 
is  used  with  advantage  in  cases  of  kyphosis  and  lordosis. 

It  is  better  to  take  the  deep  breathing  exercises  in  the  open  air, 
on  the  highest  elevation  in  a  nearby  park,  or  during  the  daily 
outing,  or  even  while  walking  to  and  from  school,  or  while  driving. 
But  one  must  adapt  himself  to  existing  conditions,  and  if  taken 
at  home  they  may  be  taken  on  a  piazza  or  balcony,  or  even 
indoors,  with  wide-open  windows,  but  the  air  should  be  as  free  from 
dust  as  possible.  If  the  windows  are  open  in  winter,  the  child  should 
wear  extra  wraps  or  clothing. 

A  breathing  exercise  should  be  preceded  by  a  number  of  strong, 
sharp  exhalations  through  the  mouth,  in  order  thoroughly  to  empty 
the  lungs  of  residual  air,  so  that  the  deep  inspirations  may  fill  the 
lungs  with  fresh  pure  air. 

The  clothing  should  always  be  loose  with  no  constrictions  at 
neck  or  waist. 

Holding  the  breath  at  the  end  of  full  inspirations  may  be  done 
to  advantage,  if  it  is  not  held  longer  than  five  seconds.  Retaining 
the  air  after  full  inspiration  causes  it  to  become  warmer.  As 
it  becomes  warmer  it  expands  and  penetrates  the  better  into  the 
alveoli.  Retaining  the  air  from  one-half  to  one  minute  or  longer 
is  not  wise.  Becoming  warmer,  it  continues  to  expand  and  may 
overdistend  and  rupture  the  alveolar  walls.  Prolonged  holding  of 
the  breath  has  also  a  deleterious  effect  upon  the  heart. 

If,  when  the  child  begins  to  take  deep  breathing  exercises  he 
feels  dizzy,  he  should  not  at  first  fill  the  lungs  to  their  greatest 
capacity,  or  hold  the  breath,  and  each  deep  inspiration  should  be 
followed  by  several  ordinary  ones.  After  a  few  days  the  dizziness 
usually  ceases. 

In  all  cases,  deep  breathing  and  respiratory  exercises  should  be 
given.  They  are  of  special  value  in  malnutrition,  constipation, 
flat  chest,  and  scoliosis. 

Breathing  Exercises. — ^Take  a  good  standing  posture. 


BREATHING 


515 


1.  Inhale  deeply  and  exhale  slowly. 

2.  Place  hands  lightly  on  lower  chest.     Inhale  deeply;    exhale. 

3.  Place  hands  lightly  on  upper  chest,  elbows  well  back  and  down. 
Inhale  deeply;  exhale. 

4.  Inhale  as  arms  are  raised  sidew^ays  to  shoulder  height.  Ex- 
hale as  arms  are  lowered. 

5.  Inhale  deeply  as  arms  are  raised  forward  and  upward,  to  a 
vertical  position.  (From  the  beginning  have  elbows,  wrists,  and 
fingers  straight,  palms  facing  each  other  and  separated  by  the 
breadth  of  the  shoulders.)     Exhale  as  arms  are  lowered  sideways. 


Fig.  59.— Breathing  Exercise. 
Inhale  as  arms  are  raised,  sideways,  upward,  to  vertical. 


6.  Inhale  as  arms  are  raised  sidewavs  to  vertical.  (Elbows, 
wrists,  and  fingers  straight — turn  palms  up  when  arms  are  shoulder 
high.)  As  vertical  is  reached,  bend  head  sHghtly  backward,  stretch 
up  and  continue  inhaling,  while  you  slowly  count  three.  Raise 
head;  exhale  as  you  lower  arms  sideways.     (See  Fig.  59.) 

In  the  illustration  the  wrists  are  strongly  flexed  and  the  palms 
are  not  turned,  in  raising  to  vertical.  The  action  is  stronger.  Either 
position  of  the  hands  may  be  used. 


5l6  GYMNASTIC    THERAPEUTICS 

7.  Arms  at  sides,  elbows,  wrists,  and  fingers  extended.  In  one 
quick,  continuous  movement  raise  arms  forward  and  flex  forearms 
upon  the  chest,  palms  down,  elbows  drawn  well  back.  At  the 
same  time  a  step  forward  is  taken — the  weight  of  the  body  is  sup- 
ported over  the  forward  foot,  the  ball  of  the  other  foot  resting  on 
the  floor.  With  the  above  movement  inhale  deeply.  Exhale  as 
the  arms  are  lowered  to  side. 

In  Nos.  4,  5,  6,  and  7,  above,  put  the  emphasis  on  the  upward 
movement.  In  lowering  the  arms,  keep  chest  high  and  arms  well 
stretched,  but  make  the  movement  an  easy  one. 

If  the  heart  is  weak,  in  the  above  exercises  the  arms  should  not 
be  raised  above  the  level  of  the  shoulders,  and  all  the  exercises 
should  be  done  more  slowly  and  with  less  exertion.  If  the  breathing 
becomes  labored,  or  the  countenance  shows  signs  of  interference 
with  circulation,  the  child  should  rest  until  pulse  and  respiration 
return  to  their  usual  rate. 

Where  deep  respiration  is  an  end  in  itself,  in  addition  to  the 
preceding  breathing  exercises,  others  which  favor  involuntary  deep 
breathing  should  be  given.  It  is  important  that  a  good  posture 
be  maintained  throughout. 

Exercises  for  Younger  Children. — i.  W^alking  up-hill  at  a  mod- 
erate pace  without  stopping. 

2.  Running  in  place,  i.  c,  executing  a  running  movement  with- 
out advancing. 

3.  Distance  running — from  fifty  yards  to  a  mile.  The  minimum 
distance  to  begin  with,  and  the  maximum  distance  to  work  up  to 
in  accordance  with  the  general  condition  and  age  of  the  child. 

4.  Running  games,  such  as  rolling  a  hoop,  playing  tag,  etc. 
Exercises  for  Older  Children — in  addition  to  those  just  mentioned : 

1.  Games,  such  as  hand-ball,  basket-ball,  tennis,  and  football 
as  played  by  boys. 

2.  Swimming  for  distance,  when  accompanied  by  a  competent 
person  in  a  boat. 

FLAT  CHEST 

In  flat  chest  the  weight  of  the  body  is  usually  carried  too  far 
back,  the  abdomen  and  head  being  too  far  forward.  The  chest  is 
flattened,  with  ribs  depressed,  and  there  is  interference  with  the 
proper  expansion  of  the  lungs.  The  shoulders  often  droop  forward. 
The  posture  is  one  of  general  relaxation. 

Flat  chest  is  of  common  occurrence  among  children  during  the 
years  of  school-life.  It  should  be  carefully  corrected  on  account  of 
the  deleterious  effect  on  the  lungs  and  abdominal  organs.  The 
necessity  for  its  correction  should  be  impressed  upon  the  child. 
Attention  to  posture  and  breathing  is  essential.  The  aim  should 
be  to  give  exercises  which  will  strengthen  the  muscles  of  the  back 
and  neck,  deepen  and  broaden  the  chest,  and  increase  its  elasticity 


FLAT    CHEST 


517 


In  addition  to  the  exercises  given  under 
[   have  found   the  following  of  benefit  in 


and  breathing  capacity. 
Posture  and  Breathing, 
these  cases : 

I.  Have  the  patient  lie  prone  on  a  hard,  flat  surface,  hold  the 
ankles  while  the  patient  raises  head  and  chest  as  far  as  possible; 
the  arms  extended  and  raised  with  the  body,  the  backs  of  the  hands 
being  turned  toward  each  other  with  the  thumbs  up.  In  the  first  few 
treatments,  the  thumbs  may  be  clasped.     Hold  position  for  from  two 


Fig.  60.— Back  Exercise. 
Raise  head  and  chest  high. 


to  five  seconds,  or  while  counting  from  one  to    five  or   ten.     (See 
Fig.  60.) 

2.  With  knees  straight,  bend  trunk  forward  until  the  hands  touch 
the  floor  in  front  of  the  toes,  or  come  as  near  to  floor  as  possible, 
then  raise  the  body  to  best  possible  standing  position.  Keep  weight 
well  over  balls  of  feet,  raise  the  chest  as  high  as  possible,  stretch 
the  arms  well  down  at  the  side;  wrists,  fingers,  and  elbows  straight. 
Hold  this  position  for  from  two  to  five  seconds  or  while  from  five  to  ten 
are  counted.  The  primary  value  of  the  exercise  is  in  the  elevation  of 
the  chest;  secondarily,  the  back  muscles  are  strengthened  and,  in 
bending  forward,  the  muscles  that  elevate  chest  are  relaxed  so  that 


they  are  better  able  to  give  a  strong  contraction  when  the  body 
is  raised. 

3.  Have  patient  seated  on  a  stool  or  low  chair  and  stand  be- 
hind him.     Patient  swings  straight  arms  forward  upward  to  vertical  \ 
palms  facing.     He  then  turns  palms  forward  and  grasps  your  hands 
and  pulls  his  elbows  backward  and  downward  close  to  sides.     As 
he  pulls  them  downward  resist  his  movement. 

KYPHOSIS 

Kyphosis,  as  considered  here,  is  an  increase  of  the  normal  curve- 
in  the  dorsal  region  of  the  spine,  commonly  called  "round-shoulders,"  ' 
produced  by  weakened  muscles  and  bad  habits  of  posture,  or  some-V 


Fig.  61.— Chest  Exercise. 
Stretch  arms  strongly. 

times  by  improperly  arranged  clothing,  and  by  the  occupation  of  the 
child.  These  causative  factors  should  be  removed  as  far  as  possible, 
and,  as  in  all  the  deformities  of  childhood,  attention  should  be 
given  to  posture,  breathing,  arrangement  of  clothing,  etc.  ■ 

The  treatment  given  under  Flat  Chest  is  appropriate  here,  as  the: 
two  conditions  are  often  associated.  The  following  exercises  may 
be  added: 

1 .  Raise  arms  sideways  to  height  of  shoulders.  Bend  head  back- 
ward with  chin  drawn  in  and  at  same  time  turn  palms  strongly 
upward.  When  patient  has  learned  to  do  this  well,  as  the  head' 
goes  back  the  arms  may  be  raised  to  vertical. 

2.  Flex  forearms  upon  chest,  palms  down  and  elbows  well  drawil. 


KYPHOSIS 


519 


back,  shoulders  level.  Incline  head  slightly  backward  and  fling 
■X  arms  forcibly  sideways. 

3.  Raise  arms  sideways  to  shoulder  level,  turn  palms  up,  make 
three  short  circles  with  arms,  stopping  at  the  backward  movement. 
Raise  arms  a  few  inches,  stretch  out  and  up.  Bring  arms  backward 
and  downward  to  sides.     (See  Fig.  61.) 

4.  Hanging  exercises : 
A  short  curtain-pole  i| 
inches  in  diameter  may  be 
placed  in  a  doorway  at 
desired  height.  Strong 
enough  sockets  can  be  ob- 
tained at  a  hardware  store. 

(a)  Hang  with  over- 
grasp. 

(6)  Hang  and  swing- 
Hanging,  is  of  much 
value  in  kyphosis  and  flat 
chest  on  account  of  its 
effect  upon  the  spine  and 
spinal  muscles. 

(c)  Holding  patient  (see 
Fig.  62) ;  trunk  of  pa- 
tient resting  against  your 
body. 

(d)  Holding  patient; 
upper  back  resting  only 
against  body. 

Exercises  "c"  and  "d" 
are  used  for  the  passive 
stretching  of  the  lumbar 
and  dorsal  portions  of  the 
spine.  The  dependent  part 
of  patient's  body  acting  as 
weight  to  stretch  the  spine. 
Hold  from  one- fourth  to 
one-half  minute.  Repeat 
several  times. 

5.  Patient  sitting  on 
stool   or   chair  with  arms 

forward  midway  between  horizontal  and  vertical,  palms  facing. 
Make  resistance  as  arms  are  separated  backward  and  downward. 
(See  Fig.  63.) 

6.  Forearms  flexed  upon  upper  arms,  hands  closed  and  facing 
the  front  of  shoulders.  Strongly  rotate  forearms  outward  and 
backward.     (See  Fig.  64.) 


62. —Weight  of  Pelvis   and    Lower   Lime 
TO  Stretch  the  Lumbar  Spine. 


520 


GYMNASTIC   THERAPEUTICS 


7.  Patient  sits  astride  a  stool  and  raises  the  arms  sideways.  With 
an  assistant,  either  the  child's  mother  or  nurse,  on  one  side  and 
yourself  on  the  other,  grasp  the  patient's  hand  with  one  hand  and 
place  the  other  hand  on  his  back  in  the  region  of  greatest  deforniitv 
Have  the  patient  pull  the  elbows  close  backward  and  downward  to 
the  sides,  against  resistance.  At  the  same  time  gentle  and  firm  pres- 
sure is  made  on  the  back. 

8.  Patient  sits  on  stool,  places  hands  low  on  hips,  fingers  for- 
ward and  wrists  straight,  elbows  drawn  well  back.     Let  him  bend 


Fig.  63.— Sit  behind  Patient  and  Give  Resistance  on  Back  of  Wrists  \s  Hi  Separates. 
His  Arms.  , 


forward  from  hips  with  back  straight.  Place  your  hands  over  the^ 
regions  of  greatest  deformity  and  have  patient  raise  the  body  against? 
resistance.  The  back  must  be  kept  straight,  head  erect,  and  chest- 
well  arched.  When  the  patient  can  do  this  well,  his  hands  may' 
be  placed  on  the  back  of  the  neck,  instead  of  on  the  hips. 

9.  The  patient  stands,  raises  arms  sideways,  shoulder  high,*! 
bends  trunk  forward  from  hips,  back  straight,  and  raises  arms  ta^ 
vertical. 

10.  Patient  lies  face  downward  over  end  of  couch  or  table,  the 
whole  body  straight,  hips  and  thighs  only,  resting  on  table  and  held*. 


SCOLIOSIS 


521 


Hands  back  of  neck.     Bend  body  forward  until   the  chest   touches 
the  seat  of  a  chair,  then  raise  body  as  high  as  possible.     (See  Fig.  65.) 
1 1 .  With  children  who  are  not  strong,  begin  with  exercises  in  a 
reclining  posture: 

(a)  Reclining   position.     Arms  extended  at    right    angle  to  the 
body,  palms  facing  each  other.     Separate  arms  against  resistance. 

(b)  RecHning  position.     Arms  extended  beyond  head  in  line  with 
the  body.     Bring  arms  sideways,  downward,  against  resistance. 

(c)  Deep  breathing. 

(d)  No.  3  under  Posture  Exercises,  but  body  arched  only  from 
hips  upward,  instead  of 

from  heels. 

The  spinal  muscles 
should  be  massaged  to 
make  them  pliable.  ^^ 


i 


SCOLIOSIS 

Scoliosis,  or  lateral 
'fcurvature  of  the  spine, 
is  a  condition  in  which 
the  spine  deviates  in 
whole  or  in  part  to  one 
side  or  the  other  of  the 
median  Hne.  It  is  ac- 
companied by  the  rota- 
tion of  the  vertebrae, 
though  in  some  cases  the 
amount  of  rotation  is  so 
slight  that  it  is  not  easily 
detected;  in  other  cases 
the  rotation  is  marked 
in  comparison  with  the 
amount  of  lateral  curva- 
ture. 

The  treatment  of  cur- 
vatures   resulting    from 
such   diseases   as   tuber- 
culosis or  caries  of  the  spine,  rickets,  etc.,  will  not  be  considered, 
but   only  the   simple   curvatures   which  occur  in.  cases  of  general 
debihty,  muscular  weakness,  or  are  the  result  of  faulty  habits  of 
posture,  a  short  leg,  certain  occupations,  etc. 

Diagnosis. — In  the  treatment  of  scoliosis,  much  depends  upon  a 
careful  diagnosis.  As  far  as  possible  all  the  etiologic  factors  should 
be  ascertained:  the  heredity,  general  constitution  and  tempera- 
ment of  the  patient;  the  general  appearance,  condition  of 
skin,  the  musculature,  its  structure  and  tonicity,  should  be  closelv 


Fig.  64.— Bring  Forearms  Back  as  Far  as  Possible. 


522 


GYMNASTIC    THERAPEUTICS 


scrutinized.  The  patient's  habits  of  posture  while  standing  and 
sitting,  especially  when  he  is  unconscious  of  observation,  should 
be  studied  carefully.  Inquiry  should  be  made  as  to  position  during 
sleep,  and  if  a  school-child,  concerning  the  desk,  and  chair  and  posi- 
tion  while  writing,  etc. 

For  examination  the  back  should  be  bared  down  to  the^ 
level  of  the  trochanters,  when  the  height  of  shoulders,  height^ 
and  prominence  of  hips,  position  of  the  scapulae  and  their  relation 
to  the  spine,  the  lines  running  from  the  tips  of  the  cars  to 
the  tips  of  shoulders,  and  the  position  of  arms  as  they  hang  at  the 
sides,  should  all  be  noted.  The  position  of  the  spine  itself  and  its 
relation  to  points  mentioned  should  also  be  closely  observed,  when 


•Fig.  65.— Movement  May  Start  from  Position  of  Complete  Flexion  or  Partial  Flex- 
ion WITH  Body  Resting  on  Seat  of  Chair  or  on  Shorter  Stand  or  Tauli:. 

the  patient  is  standing  in  his  usual  posture,  and  again  when  he  is, 
standing  in  his  best  possible  position.     The  position  of  the  spinous 
processes  should  be  marked  with  a  flesh  pencil  and  the  curve  carefully 
studied  out;  the  contour  and  relative  size  of  legs  should  be  noted  ' 
and  the  feet  should  be  examined.     To  ascertain  the  amount  of  rota-  ,=• 
tion,  the  patient  should  be  made  to  take  the  Adam's  position.^    If  any  '■■ 
difference  is  found  in  the  height  of  the  hips,  a  careful  measurement  of 
the  legs  should  be  made.     Another  important  point  to  be  determined  ' 
is  the  flexibiUtyof  the  spine,  for  to  a  great  extent  the  diagnosis  depends 
upon  this.  "j 

On  the  front  of  the  body,  the  position  of  ribs,  end  of  sternum, 
umbihcus,  and  the  tension  of  the  abdominal  muscles  should  be  hoted.  ^ 

>  Patient  stands  with  heels  together,   well  stretched,  bends  body  forward'  ■ 
from  hips;  head  and  arms  hanging  forward.  •■' 


scouosis  523 

Besides  the  above  examination,  it  is  well  to  inquire  into  the 
history  of  the  patient,  as  to  diseases  of  childhood,  present  ailment, 
liabilit}^  to  certain  diseases,  as  to  amount  of  exercise  both  outdoors 
and  indoors,  and  as  to  the  condition  of  the  digestive  organs.  Ex- 
amine heart  and  lungs.  Certain  measurements  may  be  taken,  such 
as  height,  weight,  height  sitting,  girth  of  neck,  chest,  waist,  hips, 
biceps,  calves  and  insteps,  depth  of  chest  and  abdomen,  and  breadth 
of  shoulders,  chest,  and  waist. 

I  have  found  the  best  method  of  recording  to  be  by  photographing 
the  patient,  using  a  thread  screen,  the  spinous  processes  and  lower 
border  of  scapulae  having  been  outlined  with  flesh  pencil  or  dots  of 
ink.  To  record  the  rotation,  a  lead  tape  may  be  molded  across  the 
posterior  thorax  at  point  of  greatest  convexity,  while  the  patient  is 
in  the  Adam's  position,  and  the  tape  carefully  removed  and  its  out- 
line traced  on  paper. 

The  curve  may  be  a  single  long  curve,  a  double,  or  a  triple  one. 
Endeavor  to  find  out  which  is  the  primary,  and  which  the  secon- 
dary or  compensatory  curve,  for  the  normal  position  of  the  spine  is 
the  result  of  the  adjustment  of  the  weight  of  the  body  around  the 
center  of  gravity,  in  order  to  balance  the  body  while  standing  or 
sitting,  and  if  there  is  a  change  in  the  normal  adjustment  of  the 
weight  in  one  part,  there  must  soon  be  a  corresponding  change  else- 
where, so  that  if  there  is  a  left  convexity  in  the  lumbar  region  there 
will  be  a  compensatory  curve  to  the  right  in  the  dorsal. 

Treatment. — The  treatment  should  be  both  general  and  local. 
In  the  general  treatment,  carry  out  a  thorough  hygienic  regime, 
which  includes  exercise  in  the  open  air,  baths,  attention  to  diet  and 
bowels,  clothing,  and  general  light  exercise  for  muscle-building  and 
stimulation  of  the  circulation,  respiration,  and  digestion.  One  of 
the  most  important  things  is  to  train  the  habits  of  posture. 

Special  Treaimeni. — Massage  and  exercises  which  act  strongly 
upon  the  spine  itself,  and  suspension,  with  and  without  pressure,  I 
have  found  most  useful.  It  is  occasionally  of  benefit  to  have  a 
patient  wear  a  plaster  cast  or  leather  jacket  during  the  day,  between 
treatments. 

At  first  only  general  movements  are  given,  those  in  which  both 
sides  of  the  body  are  used  equally,  such  as  those  found  under  Posture 
and  Breathing,  and  adding,  a  little  later,  the  exercises  under  Flat 
Chest  and  Kyphosis,  with  simple  movements  of  the  body  to 
strengthen  the  spinal  muscles  and  make  the  spine  more  flexible. 

The  following  may  be  used:  body-bending  forward,  backward, 
to  right  and  to  left,  and  body-twisting  to  right  and  left.  These 
movements  may  be  done  sitting  or  standing,  and  with  the  hands 
at  the  hips,  back  of  neck,  or  extended  over  head. 

'In' giving  a  new  exercise,  the  body  should  be  bare,  in  order  that 
its  effects  may  be  carefully  noted. 


524 


GYMNASTIC   THERAPEUTICS 


tHiw* 


In  giving  corrective  bending  and  twisting  movements,  the  bend-    ' 
ing  should  be  toward  the  side  of  the  convexity  with  added  pressure 
at   the   point   of   greatest   curvature,    and   the   twisting  movement 
toward  the  side,  of  the  concavity  with  pressure  over  the  point  of  the    ■ 
convexity.     The  following  are  some  of  the  special  exercises:  ^ 

A  typical  S-shaped  curve,  convexities,  right  dorsal  and  left  i 
lumbar,  has  been  taken  to  illustrate  the  treatment.  These  exer-  ] 
cises  can  be  reversed.      A  single  or  triple  curve  will  have  to  be    : 

studied    out   with    back 
bared. 

1.  Hanging  from  bar; 
pressure  over  convexities. 
(See  Fig.  66.) 

2.  Hanging  from  bar. 
Place    your    hand    over  .■ 
point    of    greatest    con- 
vexity,    and     push    pa- 
tient's body  sideways. 

3.  Hanging  from  bar. 
Have  patient  extend  the 
leg  corresponding  to  the 
side  of  lumbar  convexity 
backward  against  resist- 

x»n»^_^^^^  ance. 

•       ^Si^S^^I^^IV^  4'  Ly^^S     prone    on, 

_'•<'  ^^^^^*M^^^^Bl'  table;     left     hand     ow-^ 

-'^^^^^^Bl  neck,  right  on  hip:   raise 

^H^^^^^L  body.    (See  Fig.  60,  but 

"*  with    hands     placed    in 

accordance  with  text.) 

5.  Lying  prone  on 
table;  hands  on  neck/ 
Carry  patient's  legs  to- 
ward the  convexity  of 
the  lumbar  region. 

6.  Patient  sits  astride 
a  stool;  hands  back  of 
neck.  Twist  body  to  left; 
make  pressure  over  right 
dorsal  region. 

7.  Sitting  on  stool;  left  hand  back  of  neck,  right  at  hip;  right 
leg  extended  backward.  Bend  body  forward :  resist  patient  as  he 
raises  body,  using  pressure  over  convexities.      (See  Fig.  67.) 

8.  Standing:  flex  forearms  on  upper  arms,  with  fingers  pointing 
over  shoulders.  Extend  left  arm  upward  and  right  arm  downward 
and  backward,  and  extend  left  leg  backward. 


Fig. 


66. —Spine    Being    Stretched    by  Weight  of 
Body,  Pressure  over  Convexities. 


SCOIvIOSIS 


525 


9.  Using  wand,  that  is  about  twelve  or  fourteen  inches  shorter 
than  the  height  of  the  body;  grasp  at  ends,  with  elbows  straight; 
swing  strongly  from  front  of  thighs  to  the  right,  sideways,  backward, 
until  the  wand  is  at  a  perpendicular  and  in  line  with  the  spine.  The 
body  arches  from  heels  to  head.      (See  Fig.  68.) 

"Key-note  position."^  I^eft  arm  extended  upward;  right  arm 
sideways.     (See  Fig.  69.) 


Fig.  67.— Body  Raising  with  Pressure  over  Convexities. 

10.   (a)   Take   "key-note  position"   standing.     Stretch   body  for 
from  two  to  five  seconds. 

(6)  Take  "key-note  position."     Marching  on  balls  of  feet. 

Do  not  give  more  than  three  or  four  special  exercises  in  any  one 
treatment,  and  follow  each  of  them  with  a  marching  exercise,  such 
as  10-6,  or  some  breathing  exercise, 
best  posltioT^  position  is  the  position  of  arms  by  which  the  spine  assumes  its 


526 


GYMNASTIC    THERAPEUTICS 


CONGENITAL  ATAXIAS 
The  ataxias  of  childhood,  to  which  we  refer,  are  hereditary  cere- 
bellar  ataxia  and  hereditary   spinal   ataxia.     Most  observers  have"^ 
described  them  as  beginning  to  develop  at  the  age  of  eight  or  teiL^ 


Fig.  68.— Swing  Strong- 
ly TO  This  Position 
WITHOUT  Bending  El- 
bows. 


Fig.  69.— Key-note  Position. 


Arm  corresponding  to  low  shoulder  is  raised.  Used.?! 
to  maintain  a  better  position  of  the  spine  during  certain.  '^ 
exercises  and  marches.  f 

years;  one  or  two  observers  have  mentioned  a  much  earlier  iieriod,,.U- 
stating  that  the  s^'^mptOms  generally  appear  at  the  age  of  three  or.i' 
four  3'^ears,  and  that  the  cases  ma}^  be  congenital,  -.: 

Cases  upon  which  this  treatment  is  based  were  congenital;  the 
development  of  the  physical  movements  was  retarded  and  defective 


CONGENITAL    ATAXIAS  527 

from  the  beginning,  and  in  one  case  of  hereditary  spinal  ataxia  the 
physical  act  of  nursing  was  also  defective. 

Hereditary  cerebellar  ataxia  is  characterized  by  the  involvement 
both  of  the  upper  and  lower  limbs  at  the  same  time,  although  the 
upper  limbs  may  not  be  ataxic  to  the  same  degree  as  the  lower. 
The  gait  is  reeling,  uncertain,  with  the  feet  wide  apart,  body  bent 
forward,  the  weight  of  the  body  being  supported  mainly  upon  the 
balls  of  the  feet,  the  toes  inclining  inward,  locomotion  at  times  being 
interfered  with  by  the  crossing  of  the  legs.  One  leg  is  usually 
more  ataxic  than  the  other.  The  reflexes  may  be  increased.  The 
speech  is  hesitating,  defective,  and  explosive,  but  audible. 

Hereditary  spinal  ataxia  (Friedreich's  ataxia)  is  characterized  by 
its  beginning  in  the  lower  limbs,  gradually  extending  to  the  upper 
limbs,  and  finally  involving  the  organs  of  speech.  The  symptoms 
are  vertigo ;  swaying  from  side  to  side  on  standing ;  marked  muscu- 
lar weakness,  especially  of  the  extensors  and  abductors  (paralysis 
may  follow) ;  contractures  of  the  flexors  and  adductors ;  scoliosis 
and  talipes  resulting,  first,  postural,  through  muscular  weakness, 
later  becoming  fixed;  rheumatoid  pains;  and  diminution  or  loss 
of  the  patellar  reflex;  the  head  is  held  to  one  side  in  a  clonic  spasm, 
but  turns  from  one  side  to  the  other  every  day  or  two;  one  leg  is 
more  ataxic  than  the  other.  The  movements  are  characterized 
by  rigidity  and  incoordination;  the  articulation  is  scanning-  and 
explosive,  and  oftentimes,  for  days,  the  patient  cannot  speak  above 
a  whisper. 

Dana  states  that  there  may  be  a  mixed  or  transitional  heredi- 
tary cerebellar  and  spinal  ataxia. 

Some  observers  state  that  there  is  defective  mentality,  and  that 
the  patients  possess  a  violent  temper.  I  have  not  found  either  to 
be  true — the  temper  being  no  different  from  that  which  you  would 
find  in  a  httle  patient  otherwise  ill  for  as  long  a  period,  and  who  was 
not  perfectly  understood.  The  speech,  or  the  poise  of  the  head, 
may  suggest  deficient  mentality,  but  I  have  found  these  children 
affectionate,  observing,  and  rational,  and  showing  hereditary  indica- 
tions of  brightness  in  mechanical,  mathematical,  or  methodical  lines. 

In  beginning  treatment,  study  the  patient's  capability  for  co- 
ordinate action.  Do  this  throughout  the  entire  course.  When 
you  have  decided  upon  the  exercises  to  be  given,  show  them  to  the 
patient  in  detail,  explaining  them  fully,  so  that  he  may  understand 
what  effort  is  required,  and  occasionally,  in  teaching,  repeat  these 
illustrations  and  explanations. 

Accuracy  is  of  the  first  importance.  If  there  is  lack  of  control  in 
movement,  pause  and  hold  patient  in  correct  position  while  you  count 
from  one  to  four  or  ten  before  resuming  movement.  Follow  that 
practice  as  long  as  it  is  necessary,  and  at  every  tendency  toward 
losing  control.     Slow  and  accurate  work  first,  later  more  rapid  work. 


528  GYMNASTIC    THERAPEUTICS 

While  learning  an  exercise  of  coordination  permit  patient  to  use 
his  eyes  to  watch  his  limbs,  in  order  that  the  coordinate  centers 
may  thus  be  reinforced  or  aided.  Next  rely  only  upon  his  muscular 
sense  for  correct  execution,  and  at  last  have  the  eyes  closed  in  order 
to  eliminate  the  relationship  of  surrounding  objects,  which  might 
aid  in  the  execution.  A  reclining  posture  is  assumed  for  coordinate 
training,  where  the  patient  is  unable  to  stand. 

Do  not  expect  a  child  to  cooperate  with  you  in  attention  or  efforts 
to  make  his  physical  movements  accurate  when  he  is  left  to  himself 
for  it  is  rarely  done.  The  coordination  must  become  reflex. 
The  training  must  be  carried  to  the  extent  of  unnecessary  capability. 
"The  keynote  "  must  be,  as  with  the  orthopedist,  over-correct,  for 
the  correct  execution  of  work  under  observation  would  not  be  suffi- 
cient to  insure  coordinate  action,  the  moment  a  child  attempts  to 
do  things  alone,  or  when  he  is  tired,  or  when  his  attention  is  given 
to  other  objects. 

The  aim  in  treatment  should  be  in  keeping  with  a  child's  natural 
sphere  in  life.  Childhood  is  the  time  of  muscular  activity  and  growth ; 
it  is  the  period  of  play  and  games.  When  a  child  is  able  to  play  at 
all,  if  left  to  himself  he  will  not  stop,  for  rest,  when  he  begins  to  tire 
or  fall ;  he  will  do  so  only  when  the  game  is  ended,  and  his  companions 
finish.  Play,  therefore,  serves  only  to  increase  the  incoordination, 
because  of  overexertion.  To  make  a  child  capable  of  walking  or 
running  at  all,  makes  him  eager  to  play  when  others  play ;  but  it  is 
like  the  fencing  or  boxing  of  two  men,  one  of  whom  completely 
outclasses  the  other,  whose  native  quickness  and  strength  are  com- 
pletely overcome ;  he  has  neither  the  opportunity  to  show  them  nor 
the  mind  to  use  them.  The  ataxic  child,  in  playing  with  normal 
children,  besides  tiring  more  quickly,  being  outclassed,  becomes 
bewildered  and  cannot  seize  the  opportunity  to  attempt  coordinate 
action. 

No  satisfactory  results  can  be  expected  from  the  treatment  of 
ataxia,  unless  it  is  continued  until  the  child  is  able  to  play  as  well  as 
other  children.  The  treatment  should  be  made  practical  as  soon 
as  possible.  Do  not  spend  unnecessary  time  on  gymnastics  or 
apparatus.  When  a  child  shows  that  he  is  able  to  take  one  step, 
begin  walking  exercises,  going  up  and  down  stairs,  and  running. 

Study  the  patient's  movements,  and  analyze  his  defects  in  execu- 
tion. To  tell  a  child  not  to  fall  when  he  is  walking,  and  expect  him 
to  be  able  to  avoid  falling,  is  not  fair  to  the  child.  He  does  not  know 
why  he  falls,  and  his  attempts  to  avoid  it  only  increase  his  gen- 
eral nerve  tension.  His  faffing  may  be  due  to  one  of  several  causes: 
it  may  be  that  he  is  walking  with  his  feet  widely  separated;  if  so, 
he  gets  but  little  support  from  the  advancing  foot,  and  upon  fatigue, 
diverting  of  attention,  or  striking  a  small  obstacle,  he  will  fall. 
When  he  permits  his  feet  to  separate,  he  should  at  once  be  directed 


CONGRNITAL    ATAXIAS  529 

;  to  keep  them  close  together.  By  so  training  the  child,  it  will  become 
;  easier  to  keep  his  feet  in  position,  and,  if  there  is  no  other  defect, 
t  falling  will  unconsciously  be  avoided.  So  all  of  his  work  must  be 
I   analyzed  to  discover  its  weaknesses  or  defects. 

I  General  gymnastics  have  no  place  in  the  treatment  of  ataxia, 
but  where  certain  groups  of  muscles  are  weak,  movements  may  be 
given  to  strengthen  them,  in  order  that  they  may  do  their  part  in 
coordination.  Throughout  the  greater  part  of  the  treatment  I 
i  have  used  exercises  for  strengthening  certain  groups  of  muscles, 
although  their  primary  value  was  not  to  improve  coordination.' 
It  is  well  to  have  these  movements  executed  against  resistance,  in 
order  to  determine  the  amount  of  muscular  power  the  patient  pos- 
sesses. 

Coordinate  efforts  at  balancing  and  walking  are  first  made  upon 
the  floor  until  the  child  shows  a  little  improvement,  but  it  is 
difficult  to  make  a  child  reaUze  the  necessity  for  using  all  of  his  ener- 
gies in  the  effort,  when  he  knows  that  there  is  no  particular  danger; 
therefore  apparatus  is  necessary  to  force  coordination.  Boards, 
blocks,  and  ladders  (see  Fig.  56)  are  used,  not  for  the  purpose  of  de- 
veloping ability  to  perform  exercises  upon  them,  but  to  develop  un- 
consciously the  habit  of  constant  care  and  watchfulness,  as  the  child 
can  readily  appreciate  the  fact  that,  without  such  precaution,  he  will 
slip  and  fall ;  he  also  learns  that  he  cannot  relax,  whenever  he  is  inclined 
to  do  so,  as  he  might  were  he  on  the  floor.  By  this  apparatus  work, 
children  unconsciously  acquire  the  abiHty  to  control  themselves  in 
places  of  danger  into  which  their  play  leads  them. 

Always  place  some  incentive  before  the  child,  as  otherwise  he 
rarely  puts  forth  the  necessary  exertion.  His  interest,  attention, 
and  muscular  and  nervous  energy  must  be  exerted.  Tell  him  that 
it  is  necessary  to  do  a  certain  amount  of  work  before  the  treatment 
is  over;  that,  when  a  certain  amount  is  done,  the  treatment  for 
the  time  will  be  over,  whether  the  hour  is  up  or  not.  Tell  him  that 
he  must  do  something  more  than  he  did  the  day  before,  whether 
it  takes  longer  than  the  hour  or  not.  If  it  takes  longer  than  the 
hour,  he  will  learn  that  you  mean  what  you  say,  and  sometimes 
the  entire  work  of  the  hour  will  be  executed  in  the  last  few  minutes, 
despite  the  fact  that  the  fatigue  of  the  previous  efforts  makes  it 
more  difficult. 

While  we  wish  to  avoid  fatigue,  a  certain  amount  is  harmless. 
If  a  child  remains  fatigued  at  the  end  of  an  hour's  rest,  following 
the  treatment,  and  he  does  not  coordinate  as  well  as  before  the 
treatment,  provision  should  be  made  for  more  rest  during  the  next 
treatment.  A  child's  inertia  needs  to  be  overcome  in  spite  of 
fatigue.  It  will  teach  him  that  merely  saying  he  is  tired  wdll  not 
"enable  him  to  escape  the  work.  This  has  iaeen  impressed  upon  me 
by  seeing  how,  after  fifty-five  minutes  of  unsuccessful  effort,  a  child 

34 


530 


GYMNASTIC   THERAPEUTICS 


will  "pull  himself  together,"  as  it  were,  and  do  a  new  exercise  thai- 
may  really  be  difficult,  in  order  that  he  may  be  able  to  leave  at  tl 
end  of  the  hour. 

Never  permit  a  child  to  suffer  a  fall  or  injury  during  the  treat- 
ment. Never  take  any  risks  with  your  patient.  (See  Fig.  70 )  % 
Falls  cannot  be  prevented  in  ordinary  walking,  or  running,  except-l 
by  words  of  caution,  which  should  always  be  used;  however,  thev^ 
should  not  be  used  in  tests  when  the  patient  is  endeaA^oring  to  see  i 
-how  far  he  can  walk  or  run  before  he  falls.  On  the  first  fall,  make  ^ 
him  return. 

Experience  teaches  a  patient  distrust  of  his  abihty  to  do  a  thing' 


Fig.  70.— Walking  on  a  Narrow  Board  Several  Feet  above  the  Floor. 
An  advanced  exercise  in  coordination. 


which  he  has  never  tried,  or,  having  failed  after  several  trials,  he 
will  naturally  say  he  cannot  do  it,  and  not  wish  to  attempt  it.  Con- 
fidence must  be  inspired  in  him  to  follow  directions  unhesitatingly 
by  insisting  upon  his  accomplishing  every  task  given  him,  and  thus 
proving  his  ability  to  do  it,  and  also  by  showing  him  that  his  interest 
is  yours,  and  that  you  have  never  permitted  him  to  be  injured  dur- 
ing his  unsuccessful  attempts. 

With  a  child  it  is  not  enough  to  secure  coordinate  action,  but 
you  must  secure  endurance  along  the  lines  of  reflex,  coordinate 
action.  Coordinate  action  with  one  \\'ho  is  ataxic  calls  for  general 
tension,  and  the  unnecessary  accessory  action  of  groups  of  muscles 


CONGENITAL   ATAXIAS  53I 

is  fatiguing,  and  results  in  excessive  waste  of  nerve  and  muscle 
energy.  To  teach  a  child  to  do  his  work  easily  and  to  carry  on 
prolonged  coordinate  effort  is  thus  accomplished  by  the  same  means. 
A  parallel  can  be  found  in  a  person  learning  to  skate  or  swim.  Here 
we  have  a  general  tension  and  the  general  action  of  all  the  muscles 
of  the  body — a  great  waste  of  energy  to  prevent  one  from  falUng, 
or  going  under  the  water — and  even  after  one  has  learned  how  to 
swim,  much  of  that  nervous  waste  of  energy  will  continue  until 
he  has  thoroughly  mastered  the  art.  Endurance  and  conservation 
of  energy  are  very  desirable  in  an  ataxic. 

After  he  had  been  in  training  for  several  months  one  patient 
walked  forward,  without  stopping,  five  hundred  feet  on  the  top  of 
a  fence,  and  backward  one  hundred  and  twenty  feet  without  stop- 
ping. The  same  child  walked  several  miles  up  and  down  a  moun- 
tain-side without  stopping,  his  mind  occupied  with  observation 
and  not  applied  at  all  to  his  walking,  save  in  response  to  caution. 
He  was  able  also  to  run  half  a  mile  without  stopping  or  falHng.  It 
is  not  for  the  purpose  of  making  the  child  a  long-distance  walker 
or  runner  that,  after  he  has  learned  to  walk  or  run  properly,  the 
distance  is  gradually  increased  to  one  or  more  miles,  telling  him  to 
"take  it  as  easy  as  possible"  without  stopping,  although  when 
fatigue  is  noticed  sufficient  rest  should  be  given — it  is  common  to 
see  normal  children  of  three  or  four  years  of  age  run  and  play 
for  long  periods  of  time  without  apparently  tiring — our  object  in 
endurance  exercises  is  to  fit  the  patient  for  a  child's  sphere  in  Hfe. 
Gradually  the  muscles  become  inured  to  fatigue,  do  their  work 
with  a  minimum  expenditure  of  force,  and  to  a  certain  extent  re- 
cuperate while  in  action. 

Short  periods  of  retrogression  must  be  expected  occasionallv 
throughout  the  entire  course.  When  a  child  is  tired,  has  had  excite- 
ment, or  when  he  is  indisposed,  one  must  expect  a  temporary  loss 
of  coordination.  Parents  too  should  be  prepared  for  this,  and  not 
be  disheartened  when  it  occurs. 

The  life  of  an  ataxic  child  should  be  quiet  and  free  from  excite- 
ment. Judgment  should  be  used  about  allowing  him  to  mingle 
with  other  children,  even  though  they  are  members  of  his  own 
family.  When  allowed  to  play,  it  should  be  with  younger  children, 
if  possible,  or  with  his  nurse,  or  mother,  until  the  time  of  playing 
with  other  children  is  made  a  part  of  the  treatment,  and  even  then 
it  should  be  confined  to  lines  permitted  by  the  one  in  charge.  In 
the  intervals,  a  child  needs  sufficient  quiet  and  rest,  so  that  he  will 
completely  recuperate,  and  be  in  the  best  possible  condition  for  the 
next  treatment,  as  the  treatments  afford  the  only  hope  of  restoring 
him  to  nerve  stability  and  normal  muscular  movement.  As  he 
improves,  however,  the  daily  regime  should  vary.  As  a  rule,  a 
child  should  rest,  lying  down  from  one- half  hour  to  an  hour  before 


532  GYMNASTIC    THERAPEUTICS 

treatment,  and  the  same  length  of  time  after  treatment,  and,  in 
fact,  at  any  time  during  the  day  when  incoordination  becomes 
marked. 

Attention  to  the  general  health  of  the  child  is  important.  There 
should  be  a  simple  and  nutritious  diet,  careful  attention  to  the  bowels, 
daily  bathing,  an  outdoor  life,  taking  the  treatment  whenever  possi- 
ble in  the  open  air.  These  things  should  not  be  neglected,  as  these 
patients  are  apt  to  have  less  resistance  to  disease  than  non-ataxic 
children. 

Illness  does  not  cause  a  retrogression  except  temporarily  through 
the  weakness  which  follows  it.  With  returning  health  and  strength, 
progress  continues. 

Cooperation  is  important.  It  is  more  necessary  here  than  in 
any  other  chronic  ailment.  A  child  will  recover  in  one-half  the 
time  if  cooperation  is  conscientiously  given  by  those  in  charge  of 
the  child.  For  illustration:  the  child  is  capable  of  walking,  but 
walks  on  the  balls  of  his  feet,  or  crosses  his  feet  frequently,  causing 
him  to  lose  his  balance  easily;  whenever  he  does  it,  if  he  is  called 
back,  no  matter  what  his  object  may  be  for  going,  until  he  has 
walked  across  the  floor  correctly,  the  next  time  he  starts  to  walk 
it  will  not  be  necessary  to  call  him  back  as  many  times,  and  the  con- 
stant correct  walking  will  gradually  make  it  a  reflex  habit.  If  he  is 
permitted  to  walk  incorrectly  it  encourages  incoordination  and  a 
careless  habit.  The  course  of  nervous  stimuli  has  been  likened  to 
the  making  of  a  new  path  in  a  jungle.  Constant  use  will  make  it 
easy  to  travel,  but  if  the  old  path  of  incoordination  is  used  instead, 
the  new  path  of  coordination  remains  a  difficult  task  for  a  much 
longer  period  of  time.  The  lines  of  least  resistance  are  followed, 
and  the  new  must  be  made  as  easy  as  the  old  if  we  would  have  a 
child  use  it. 

Treatment  should  be  for  an  hour  daily.  More  than  an  hour's 
treatment  is  apt  to  produce  general  nervous  fatigue.  An  ataxic  child 
may  need  training  along  many  lines,  and  the  attempts  to  do  one 
thing  correctly  may  require  so  long  a  time  that  it  is  unwise  to  at- 
tempt to  give  work  for  the  correction  of  all  at  one  treatment.  If 
this  is  attempted,  nothing  will  be  well  done  in  the  hour,  and  the 
work  will  only  serve  to  tire  the  patient  and  increase  the  incoordina- 
tion. It  would  take  a  normal  person,  who  could  do  the  movements 
well,  more  than  one  hour  to  cover  all  the  lines  with  improvement  in 
each.  An  hour  has  been  spent  in  endeavoring  to  walk  a  plank  once 
without  falling  off,  but  the  child  did  it  before  the  treatment  was 
completed,  and  the  next  day  he  did  it  twice,  so  there  was  evident 
progress.  When  one  morning  hour  is  given  to  the  lower  limbs,  work 
might  be  mapped  out  so  that  an  assistant,  the  mother  or  nurse,  could 
give  another  hour,  or  half  hour,  in  the  afternoon  to  exercises  for  the 
arms  and  fingers,  or  to  massage,  which  would  improve  the  nutri- 


CONGENITAL   ATAXIAS  533 

tion  of  the  tissues  and  the  general  circulation,  so  as  to  insure  a 
better  general  response  of  the  nerves  and  muscles.  Another  half 
hour  could  be  spent  in  training  the  speech  of  the  child.  In  this  way 
the  correction  of  the  upper  Hmbs  and  speech  could  progress  at  the 
same  time  as  that  of  the  lower  limbs,  instead  of  waiting  until  after 
the  coordination  in  the  lower  limbs  is  first  secured. 

Improvement  in  one  line  does  not  imply  any  special  improve- 
ment in  another.  Walking,  running,  going  up  and  down  stairs, 
jumping,  and  hopping  must  each  be  taken  up  separately.  It  is 
particularly  true,  in  case  one  is  working  for  improvement  in  the 
lower  limbs,  and  Httle  attention  is  given  at  the  same  time  to  the 
upper.  At  the  end  of  the  time  devoted  to  locomotion,  the  ataxia 
of  the  upper  limbs  is  but  little  improved. 

Parents  and  physicians  occasionally  think  that  a  child  will  out- 
grow his  ataxia,  but  this  is  a  mistake. 

A  patient  should  hold  as  good  a  posture  as  possible  at  all  times, 
as  the  weight  of  the  body  is  then  better  adjusted.  One  or  two 
exercises  under  Posture  should  be  added  to  the  treatment.  The 
suggestions  about  clothing,  under  Posture  (page  509),  are  especially 
valuable  here. 

Five  or  ten  minutes  once  or  twice  a  day  should  be  devoted  to  a 
sitting  posture  in  which  the  body  is  held  erect,  but  the  limbs  relaxed, 
and  every  part  of  the  body  entirely  at  rest.  This  aids  greatly  in 
overcoming  the  nervous  instability  and  irritability,  and  is  a  valua- 
ble help  in  securing  general  nervous  control. 

When  giving  the  patient  his  treatment  there  should  be  no  one 
else  in  the  room,  unless  it  is  one  whose  presence  would  aid  in  securing 
better  attention  or  work  from  the  child. 

There  is  difference  in  the  treatment  of  congenital  ataxias  and 
that  of  locomotor  ataxia:  In  one  case  the  patient  is  a  child,  in  the 
other  an  adult.  With  the  child,  between  treatments  there  is  little  or 
no  cooperation;  with  an  adult  there  is  cooperation.  During  the 
period  of  development  a  child's  sphere  is  that  of  play  and  muscular 
activity.  The  adult  looks  forward  only  to  returning  to  his  busi- 
ness or  professional  activity,  and  stops  treatment  when  his  pro- 
ficiency and  coordination  permit  this. 

Exercises. — In  the  beginning,  when  the  child  cannot  walk,  ex- 
ercises should  be  taken  while  lying  down.  For  the  lower  limbs, 
they  consist  of  coordinate  flexions  and  extensions,  abductions,  ad- 
ductions, and  circumductions,  actively  and  against  resistance,  and  of 
touching  certain  designated  points  or  objects  with  the  feet  separately. 
In  cerebellar  ataxia  one  can  more  readily  advance  to  the  standing 
exercises,  and  take  foot-placings  (floor  may  be  marked  for  this), 
stepping  out  to  side,  front  and  back  and  to  the  ordinary  oblique 
positions,  forward  and  backward.  The  weight  of  the  body  is  carried 
by  the  advancing  foot,  so  that  when  the  movement  is  completed 


534  GYMNASTIC    THERAPEUTICS 

the  weight  rests  equally  over  both  feet.  Taking  a  step  is  now  prac- 
tised, bringing  up  the  other  foot  to  the  side  of  the  foot  advanced. 
This  is  done  sideways,  forward,  and  backward.  Two  or  three  steps 
are  now  attempted,  a  pause  being  made  after  each  one  until  a  per- 
fect poise  of  the  body  is  obtained.  This  is  continued  until  the  child 
can  walk  across  the  room.  At  this  time  the  defects  shown  in  the 
walking  should  receive  attention. 

The  defects  in  walking  or  running  are  usually  the  following: 
carrying  the  weight  of  the  body  too  far  forward;  not  straightening 
the  knees  completely;  the  reeling  gait;  the  crossing  of  the  legs; 
walking  with  the  feet  separated ;  turning  the  toes  inward ;  not  lifting 
the  feet  sufficiently;  not  bringing  the  heels  to  the  ground.  As 
occasion  arises,  show  the  child  his  defects,  and  caution  him  against 
their  repetition.  In  walking  and  running  in  the  room,  repeat  the 
exercise  if  any  faulty  execution  is  noted.  Instruct  the  members 
of  the  household,  who  have  charge  of  the  child,  never  to  ignore 
these  defects,  but  always  to  insist  upon  their  immedia,te  correction. 
In  the  outdoor  walking  or  running,  the  patient  should  always  be 
in  advance  of  you,  so  that  his  every  movement  may  be  observed. 
It  is  here  that  the  correction  of  the  defects  should  mainly  take 
place.  The  following  four  movements  aid  in  correction,  and  should 
be  given  every  day  for  quite  an  extended  period,  in  order  that  the 
weakened  muscles  may  be  strengthened  for  the  required  work  of 
coordination : 

(a)  Drawing  up  the  knees  against  resistance ; 

(b)  Flexing  the  toes  against  resistance ; 

(c)  Abduction  of  feet  against  resistance; 

(d)  Extension  of  legs  against  resistance. 

In  the  full  extension  of  the  legs,  the  feet  must  be  kept  flexed. 

The  child  being  able  to  walk  across  the  room,  work  is  begun  upon 
the  apparatus ;  boards  from  7  inches  down  to  i  inch  in  width  by  half 
an  inch  in  thickness  and  10  feet  in  length,  of  well-seasoned  hard- 
wood; a  ladder,  the  sides  of  which  are  i^  by  2^  inches,  10  feet  in 
length,  and  the  rounds  |  inch  in  diameter  by  12  inches  long,  placed  10 
inches  apart  in  the  ladder ;  24  blocks  of  wood,  2  inches  in  thickness 
and  12  inches  wide  by  14  inches  long.  Beginning  with  the  7-inch 
board,  have  the  child  walk  over  and  back,  with  the  arms  in  different 
positions,  the  eyes  open  and  the  eyes  shut;  one  end  of  the  board 
placed  upon  one  block,  and  so  on  until  one  end  is  resting  upon  ten 
or  more  superimposed  blocks.  The  board  is  placed  upon  supports  of 
equal  height,  beginning  with  one  block  under  each  end,  increasing 
the  height  until  the  board  is  about  five  feet  from  the  ground.  At 
each  increase  in  height  the  various  exercises  are  repeated.  (See  Fig. 
70.)  Two  five-inch  boards  can  be  used  when  placed  upon  the' 
same  supports,  the  boards  being  about  eight  or  ten  inches  apart. 
The  child  can  step  from  one  board  to  the  other,  going  from  one  end 


CONGENITAL    ATAXIAS 


535 


to  the  other;  and,  standing  in  the  center,  he  can  step  forward  and 
backward  from  board  to  board.  With  boards  placed  together,  walk 
forward  and  backward,  the  boards  bending  unevenly,  as  one  foot  is 
on  each  board. 

Using  the  blocks  alone,  arrange  them  for  walking,  at  varying 
distances  from  each  other;  also  make  piles  uneven  in  height,  and 
have  patient  walk  with  the  eyes  open  and  the  eyes  shut  on  the  blocks. 


Fig.  71.— Walking  on  Rounds  of  Ladder,  One  End  Raised  Several  Feet  above  Floor- 
AN  Advanced  Exercise  in  Coordination. 


Ladder  Exercises. — Ladder  fiat  on  the  ground,  walking  forward  in  the 
spaces  between  the  rounds;  walking  sideways  and  walking  backward. 
Place  one  end  of  the  ladder  upon  a  block  and  add  blocks  gradually 
until  the  ladder  reaches  the  height  of  the  child's  knee ;    then  begin 


536  GYMNASTIC    THERAPEUTICS 

with  both  ends  of  the  ladder  placed  on  single  blocks,  gradually  in- 
creasing the  height  until  the  ladder  reaches  the  height  of  the  knee ;  after 
each  change  of  height  the  walking  exercise  forward,  sideways,  and 
backward  is  repeated.  When  using  the  blocks  the  child  may  bring 
them  from  the  pile  and  build  the  steps  that  he  is  to  walk  upon; 
standing  upon  the  block  previously  placed  upon  the  floor,  he  bends 
forward,  placing  in  position  the  one  he  carries,  repeating  the  process 
until  all  the  blocks  are  arranged.  When  through  walking  over  the 
blocks,  he  stands  on  the  one  next  to  the  last  one  placed,  bends  over 
and  picks  up  the  last  one,  and  may  carry  it  back  to  the  pile,  walking 
over  the  blocks,  or  he  may  lift  and  raise  it  above  the  head,  and  pass 
it,  either  forward  or  backward,  to  you.  The  block  may  be  carried 
by  the  child  walking  through  the  spaces  of  the  ladder,  and  both 
ladder  and  blocks  may  be  arranged  in  various  forms  to  be  walked 
over  by  the  child. 

You  may  now  take  up  the  balancing  work,  where  the  weight  of 
the  body  is  carried  on  only  a  portion  of  the  sole  of  the  foot,  as  in 
walking  on  the  rounds  of  the  ladder.  The  ladder  is  first  placed  flat 
upon  the  ground,  and  the  walking  is  done  forward  and  backward. 
This  is  graded  by  raising  one  end  of  the  ladder  until  the  child  can 
walk  up  and  down  on  the  rounds  several  times  without  a  mistake, 
the  ladder  raised  to  an  angle  of  35°.      (See  Fig.  71.) 

In  beginning  the  treatment,  the  child  is  instructed  not  to  allow 
one  foot  to  step  directly  in  front  of  the  other.  By  this  time  co- 
ordination is  sufficiently  mastered  so  that  balancing  as  an  exercise 
may  be  taken  up,  using  the  boards  from  2  inches  down  to  one  inch 
in  width.  On  these  boards  the  child  must  place  one  foot  in  front  of 
the  other,  and  walk  forward  across  it;  next,  walk  backward,  eyes 
open  and  eyes  shut. 

When  a  child  is  able  to  walk  fifty  or  sixty  feet  without  falling  or 
stopping  to  rest,  the  distance  is  gradually  increased  in  outdoor 
walks,  correcting  defects  when  noticed,  until  he  can  walk  a  miile  or 
more  without  their  occurrence  or  without  falling. 

When  able  to  run  across  the  room  in  a  straight  line,  teach  running 
in  a  circle.  W^atch  closely  his  running  and  do  not  allow  the  feet  to 
be  widely  separated,  or  the  weight  of  the  body  to  incline  too  much 
forward.  He  should  run  with  a  firm  stride  and  raise  his  feet  well.  In- 
crease distance  until  he  can  run  half  a  mile  without  falling  or  stopping 
to  rest.  Later  teach  running  up  and  down  hill ;  running  short  dis- 
tances, as  from  eighty  to  one  hundred  feet,  as  fast  as  he  can,  and  stop- 
ping without  falling;  trying  to  catch  a  person;  racing  with  another 
child,  who  starts  at  a  sufficient  distance  behind  him,  so  that  they 
will  finish  at  about  the  same  time ;  running  to  catch  a  person  who 
will  dodge  and  run  zig-zag  and  in  circles.  Playing  with  other  chil- 
dren in  running  games,  such  as  "cross-tag,"  "pull  away,"  etc.,  hav- 
ing the  other  children  so  handicapped  that  by  exerting  himself  to  the 


CONGENITAL    ATAXIAS 


537 


utmost  he  will  not  be  caught.  During  these  games,  if  he  falls,  he 
should  be  obliged  to  run  around  the  grounds  once  alone. 

Other  indoor  exercises  are:  whirhngononefoot  fifty  times  without 
falling;  repeat  on  the  other  foot ;  alternate  thus  with  eyes  open  and  eyes 
shut ;  running  in  a  short  circle  fifty  times  without  falling.  Such  exer- 
cises are  helps  to  the  running  out  of  doors.  Another  helpful  exercise 
is  running  several  hundred  feet  out  of  doors,  whirling  around  in 
the  direction  indicated  whenever  the  command  "turn  right,"  or 
"turn  left,"  is  given,  without  falling. 

Walking  Up  and  Down  Stairs. — Begin  wuth  one  or  two  steps  and 
gradually  increase  until  the  length  of  the  flight  is  reached,  seeing 
that  the  feet  are  not  separated,  but  that  they  advance  in  straight 
lines  directly  in  front  of  the  body.  In  walking  up  stairs,  carry  the 
weight  of  the  body  over  the  foot  that  is  on  the  upper  stair.  In  walk- 
ing down  stairs,  be  sure  that  the  heel  is  brought  against  the  back  of 
the  stair,  so  that  the  foot  at  no  time  will  rest  on  the  edge.  Keep  the 
hands  close  to  the  sides  of  the  body  while  walking  up  and  down  stairs 
with  the  eyes  shut.  Run  up  and  down  stairs  with  the  eyes  open 
and  again  with  eyes  shut,  carrying  articles  W'hile  running.  Always 
be  near  enough  to  the  child  for  his  protection  in  case  of  accident. 
The  object  is  to  train  the  muscular  sense  and  make  the  coordination 
sufficiently  reflex  to  enable  the  child  to  run  or  walk  up  the  stairs 
alone  without  the  danger  of  an  accident. 

Jumping. — Draw  a  line  with  a  piece  of  chalk;  teach  the  child 
to  inchne  his  body  sHghtly  forward,  bending  knees  a  Httle,  spring 
forward,  aided  by  an  upward  swing  of  his  arms.  Jump  for  height 
and  distance  over  the  rounds  of  the  ladder,  from  one  space  to  another, 
and  repeat,  skipping  one  space.  Jump  from  block  to  block,  the 
blocks  being  separated  at  varying  distances.  Jumping  over  blocks; 
running  and  jumping. 

Hopping. — Hopping  is  much  more  difficult,  as  the  spring  is  from 
one  foot  alone,  and  the  landing  on  the  same  foot.  In  addition  to  the 
coordination  necessary  to  balance  upon  one  foot,  is  added  the  required 
effort  to  lift  the  body  from  the  ground  and  the  coordination  required 
for  balancing  the  body  on  landing,  so  as  to  avoid  falHng.  The 
training  is  about  the  same  as  in  jumping;  hopping  with  either  foot 
over  a  string;  hopping  for  distance ;  hopping  for  height ;  and  making 
a  succession  of  hops  on  the  same  foot,  without  touching  the  other 
foot  to  the  ground ;  the  running  hop. 

At  the  close  of  these  exercises  it  may  not  be  amiss  to  repeat  what 
was  stated  at  the  beginning,  that  it  is  not  desired  to  make  the  child 
an  athlete,  but  distance  walking,  distance  running,  fast  running, 
jumping,  and  hopping  are  exercises  which  children  use  in  their  play 
for  long  periods  of  time,  and  the  coordination  secured  by  the  appa- 
ratus work  is  often  of  value  in  places  of  danger  where  their  play  is 
often  apt  to  lead  them.    Coordination  to  this  degree  should  be  secured. 


538  GYMNASTIC    THERAPEUTICS 

Exercises  for  the  Upper  Limbs. — In  the  beginning,  the  general 
movements  of  the  fingers,  wrists,  forearms,  upper  arms,  and  shoulders 
may  be  practised,  executing  them  slowly  until  the  coordination  is 
perfect  in  these  movements.  The  above  exercises  are  simple  move- 
ments of  flexion,  extension,  rotation,  and  circumduction.  The 
educative  movements,  however,  have  mainly  to  do  with  the  fingers. 

1.  Flexing  and  extending  the  fingers. 

2.  Slowly  and  gently  touch  the  tip  of  the  thumb  to  the  tip  of 
each  finger  and  hold  them  together  without  pressure  while  five  is 
counted. 

3.  Simultaneously  touch  the  tip  of  each  finger  to  the  tip  of  the 
thumb. 

4.  Flex  strongly  the  index-finger  so  that  the  end  will  touch  the 
base  of  its  second  metacarpal  bone. 

5.  Flex  strongly  and  adduct  the  thumb  so  that  the  tip  of  the 
thumb  will  press  the  tip  of  the  little  finger. 

6.  Flex  strongly  and  adduct  the  thumb  so  that  its  tip  will  press 
the  base  of  the  little  finger. 

7.  Needles:  have  them  graded  from  the  largest  to  the  smallest 
size,  grasp  a  fine  thread  between  thumb  and  each  finger  of  one  hand 
in  turn,  and  thread  each  needle ;  repeat,  using  the  other  hand. 

8.  Buttons:  have  them  graded  from  the  largest  to  the  smallest 
obtainable,  and  have  them  sewed  on  to  one  strip  of  cloth,  another 
strip  of  cloth  having  buttonholes  to  correspond.  Practise  buttoning 
and  unbuttoning  with  thumb  and  index-finger  of  each  hand. 

9.  Pins:  picking  them  up  with  hand.  Pick  up  the  pins  and  press 
them  through  a  stiff  pasteboard  box,  forming  various  designs. 

10.  With  a  pencil  correctly  held,  make  squares,  triangles,  parallel 
lines,  etc.,  with  and  without  dots  as  a  guide. 

11.  With  a  pencil  correctly  held,  make  figures  and  letters  both 
large  and  small. 

The  child  can  also  use  the  exercises  of  piling  coins  and  chips, 
touching  hanging  balls,  placing  pegs  in  holes,  and  similar  games. 
Also  throwing  and  catching  a  ball.  A  child  should  be  made  to  dress 
and  undress  himself,  and  to  feed  himself,  although  as  exercises, 
at  the  beginning,  he  may  do  them  only  in  part. 

In  eating,  the  spoon  or  fork  should  never  be  full,  and  the  cup  or 
glass  should  be  only  partly  filled.  The  execution  of  the  move- 
ments should  be  slow. 

Exercises  for  the  Speech. — A  child  should  be  taught  to  enunciate 
numbers  and  letters  distinctly.  An  interesting  book  should  be  read 
to  him,  reading  one  or  more  words  at  a  time,  and  requiring  him  to 
repeat  them  correctly  after  you. 

Friedreich's  Disease. — In  a  well-marked  case,  begin  treatment  with 
massage  to  improve  the  nutrition  of  the  weakened  and  atrophied  mus- 
cles and  to  help  relax  the  spasm  in  the  contracted  muscles.     In  con- 


ANTERIOR    POLIOMYELITIS  539 

nection  with  the  massage,  passive  exercise  of  the  Hmbs  is  given  and 
gradual  and  persistent  extension  is  made  upon  the  contractures, 
endeavoring  to  gain  a  Uttle  each  day  until  the  limbs  are  fully  ex- 
tended; then  increase  from  day  to  day  the  time  during  which  the 
hmb  is  held  at  full  extension  and  abduction.  The  degree  of  motion 
in  the  joints  is  utilized  by  giving  active  movements.  In  order 
that  the  muscles  may  become  stronger,  slight  resistance  is  given  to 
these  movements,  and  greater  attention  paid  to  the  strengthening 
of  the  weaker  groups  of  muscles.  When  the  muscles  have  moved 
the  limbs  as  far  as  possible,  the  extension  must  be  completed  by 
stretching  or  by  pressure.  A  child  should  be  taught  how  to  turn 
over,  after  pushing  up  his  arms  out  of  the  way.  When  lying 
prone  he  should  try  to  draw  up  his  knees  under  his  body,  and  when 
his  arms  become  flexible  enough  and  strong  enough,  he  should  raise 
up  his  body  until  he  rests  on  his  hands  and  knees;  later  he  is 
required  to  raise  himself  until  he  is  sitting  upon  his  legs,  which  are 
flexed  underneath  his  thighs.  Have  patient  raise  his  body  from  a 
reclining  to  a  sitting  posture,  with  legs  extended.  Let  him  sit  in 
a  chair,  which  is  low  enough  to  permit  him  to  place  his  feet  upon  the 
floor,  but  without  any  supporting  arms.  Let  him  rise  from  a  sitting 
to  a  standing  posture  by  drawing  back  his  feet  underneath  him, 
and  inclining  his  body  slightly  forward,  then  straightening  up  to  a 
standing  posture.  Have  him  balance,  upon  standing,  from  a  few 
seconds  to  several  minutes,  stretching  his  body  up  to  its  full  height. 
Give  foot-placings,  then  let  him  attempt  a  few  steps,  pausing  after 
each  step  to  straighten  up,  balance  and  "make  himself  tall."  From 
this  point  the  treatment  is  the  same  as  that  of  the  ataxia  of  the  cere- 
bellar type,  except  that  the  massage  and  work  for  overcoming  the 
contractures  must  be  continued  indefinitel)^,  or  the  progress  will 
be  slower. 

ANTERIOR  POLIOMYELITIS 

Exercises  should  include  action  of  all  the  groups  of  muscles  of 
the  limbs.  The  exercise  of  the  muscles  that  are  normal,  or  but 
little  impaired,  stimulates  the  nutrition  of  the  neighboring  impaired 
muscles. 

With  the  patient  in  a  reclining  position  the  thighs  may  be  flexed, 
extended,  abducted,  adducted,  and  circumducted  against  resistance 
when  possible.  The  leg  may  be  flexed  and  extended,  and  the  foot 
may  be  flexed,  extended,  abducted,  and  circumducted.  These  move- 
ments ma}^  be  passive  at  first;  later,  when  possible,  they  may  also 
be  taken  standing.  Flexion  and  abduction  of  the  foot  and  extension 
of  the  toes  are  results  which  will  come  last. 

A  faint  response  is  sometimes  seen  after  friction  over  the  super- 
ficial points  of  the  nerves  supplying  these  muscles,  or  when  the 
limb  is  immersed  in  hot  water,  and  when  seen  the  movements  should 


540  GYMNASTIC    THERAPEUTICS 

be  completed  passively.  As  the  muscles  show  signs  of  returning 
functions,  the  movements  are  repeated  frequently  during  the  day, 
but  always  stopped  when  the  responsive  motion  becomes  weaker, 
in  order  that  fatigue  may  be  avoided.  When  possible,  the  lightest 
resistance  should  be  given,  so  that  the  power  of  the  muscles 
may  be  better  ascertained,  and  their  work  thus  gradually  increased 
by  increasing  the  resistance.  An  added  stimulus  may  be  given  by 
having  the  normal  limb  execute  the  movement  with  the  paralyzed 
limb.  Occasionally,  movement  is  secured  in  all  but  one  toe.  Where 
there  is  improvement  in  any  way  in  the  paralyzed  limb,  the  treat- 
ment should  be  continued,  for  cases  have  shown  that  muscles  may 
respond  to  treatment  even  though  there  may  be  no  faradic  reaction 
for  more  than  a  year. 

When  the  patient  is  able  to  walk,  walking  and  marching  exer- 
cises should  be  taken  up,  such  as  walking  on  straight  lines  to  and  from 
certain  objects,  walking  on  the  toes,  walking  with  the  arms  sideways 
shoulder  high,  and  with  arms  in  a  vertical  position.  The  blocks, 
board,  and  ladder  that  are  used  in  treating  ataxic  patients  pre- 
viously described  are  of  use  here.  A  trough  or  the  use  of  a  narrow 
ladder  with  sides  six  or  eight  inches  in  width  serves  to  help  the 
patient  overcome  the  outward  throw  of  the  paralyzed  leg.  Although 
the  dimensions  of  the  ladder  are  different,  the  walking  exercises 
outhned  in  the  treatment  of  ataxia  may  be  followed  in  part.  In 
walking,  the  patient  should  endeavor  to  keep  the  foot  flexed  as  much 
as  possible,  touching  the  heel  first  in  bringing  down  the  foot.  The 
following  may  also  be  given:  walking  on  the  heels  for  a  short  dis- 
tance; jumping;  cHmbing  a  ladder,  using  hands  and  feet;  running, 
but  do  not  permit  an  outward  throw  of  the  paralyzed  leg,  it  must 
advance  straight  forward;  hanging  from  a  bar,  swinging  both  legs 
forward,  sideways  and  backward,  keeping  heels  together,  and  with 
feet  apart.  A  light  basket-ball  or  foot-ball  may  be  used  for  kick- 
ing. Have  patient  practise  the  drop-kick,  and  show  you  how  hard 
he  can  kick. 

Exercises  for  the  Arms. — Flexion,  extension,  abduction,  adduc- 
tion, and  circumduction  of  the  upper  arm;  flexion,  extension,  and 
rotation  for  the  forearm  and  wrist,  with  and  without  resistance. 
Have  patient  close  hand  as  tight  as  possible,  showing  how  hard  he 
can  strike.  Have  him  catch  a  basket-ball  and  practise  throwing 
it  into  a  high  basket  at  different  distances.  Drop  a  tennis-ball  into 
his  hands  to  catch;  also  toss  and  bound  it  for  him  to  catch.  Have 
him  throw  a  tennis-ball  for  height  and  distance.  The  tendency  is  to 
throw  the  ball  downward.  Some  of  the  special  finger  movements  used 
in  the  treatment  of  ataxia,  such  as  approximating  the  tip  of  the 
thumb  and  the  tips  of  the  fingers,  the  button  exercise,  the  work  with 
the  pencil,  etc.,  may  also  be  given.      (See  page  538.) 

Passive  Exercises. — Where  there  is  any  tendency  to  contracture 


CONSTIPATION  54I 

in  the  groups  of  muscles  not  paralyzed,  or  in  which  the  degree  of 
paralysis  is  only  slight,  passive  exercises  should  be  given  to  secure 
a  normal  range  of  motion  of  the  contracted  groups  either  in  leg  or 
arm.  This  must  be  kept  up  throughout  the  treatment  for  the  pur- 
pose of  lessening  or  overcoming  the  tendency  to  deformity.  Care 
should  be  used,  however,  in  not  carrying  the  passive  motion  beyond 
the  normal  range. 

Resistance  applied  to  movements  of  contracted  muscles  serves 
to  stretch  them  more  than  does  the  passive  stretching. 

Massage. — Gentle,  deep-kneading,  light  clapping  and  hacking, 
friction  over  the  superficial  points  of  the  nerves,  and  general  fric- 
tion should  be  given  to  the  entire  limb. 

Light  hacking,  vibration,  and  deep-kneading  should  be  given 
to  the  spinal  muscles. 

Fifteen  minutes  of  massage  should  be  given  once  or  twice  daily 
as  long  as  the  treatment  is  needed. 

CONSTIPATION 

In  addition  to  the  measures  suggested  in  a  previous  section  (pages 
170-175)  for  the  rehef  of  constipation,  gymnastic  exercises  may 
be  brought  into  use. 

These  exercises  are  given  with  two  objects  in  view:  one,  to 
strengthen  the  abdominal  walls,  which  mechanically  stimulate  the 
intestine;  the  other,  to  stimulate  the  general  circulation,  which 
quickens  the  portal  circulation  and  increases  the  activity  of  the  liver. 

The  first  five  exercises  are  taken  from  a  reclining  position. 

1.  The  knees  straight  and  feet  extended.  Raise  both  legs  until 
they  are  at  a  right  angle  with  the  body. 

2.  Knees  straight.  Raise  heels  about  four  inches  above  couch; 
separate  them  as  widely  as  possible ;  bring  them  together,  and  lower 
to  couch. 

3.  Knees  straight.  Raise  heels  ten  or  fifteen  inches  above 
the  couch.  Draw  up  the  knees  as  close  to  the  chest  as  possible, 
without  raising  heels.  Extend  the  legs  without  raising  or  lowering 
the  feet.     Lower  legs  to  couch. 

4.  Feet  held,  or  secured  by  strap.  Raise  body  to  sitting  position 
without  use  of  hands.  The  hands  may  be  placed  upon  the  thighs, 
folded  upon  the  chest,  placed  back  of  neck,  or  the  arms  may  be  ex- 
tended beyond  the  head.  Changing  the  position  of  arms  in  the 
order  named  increases  the  exertion. 

5.  Feet  held.  Circle  trunk  sideways,  forward,  sideways,  back- 
ward to  the  starting  position.  Starting  to  right  and  left  alternately. 
Arms  position  as  in  number  four. 

6.  Hang  from  bar  or  round  of  ladder.  Execute  No.  i.  (The 
position  of  body  changed,  but  the  relation  of  legs  to  body  same  as 
in  No.  I.) 


542  GYMNASTIC    THERAPEUTICS 

7.  Hanging  position.     Execute  No.  2. 

8.  Hanging  position.     Execute  No.  3. 

9.  Hanging  position.  Heels  together,  swinging  legs  from  waist, 
describe  as  large  a  circle  as  possible  with  the  feet. 

Each  of  the  above  exercises  may  be  followed  by  a  deep-breathing 
exercise. 

In  a  weak  patient,  the  detail  of  straight  knees  need  not,  at  first, 
be  insisted  upon.  If  necessary,  the  patient  may  be  assisted,  the 
weight  of  the  legs  or  body  being  partly  supported  until  the  patient 
is  strong  enough  to  execute  it  alone. 

10.  Sitting  on  chair  or  stool.  Hands  placed  back  of  neck,  twist 
body  right  and  left  against  resistance. 

11.  Sitting  position.  Hands  back  of  neck,  bend  body  right 
and  left  against  resistance. 

Exercises  for  the  General  Circulation. — Taken  from  a  standing 
position. 

1.  Bend  trunk  forward,  touch  floor  with  fingers,  keeping  the  knees 
straight. 

2.  Take  a  long  step  forward,  bend  the  forward  knee;  bend  trunk 
forward;  touch  the  floor  with  fingers.  Raise  trunk,  step  back  to 
position.     Alternate  feet  in  stepping. 

3.  Stand  with  feet  two  foot-lengths  apart.  Raise  arms  side- 
ways to  shoulder  height.  Bend  right  knee  and  bend  trunk  to  right 
side,  touching  floor  with  right  hand.     Raise  body.     Same  to  left. 

4.  "Chopping."  Stand  with  feet  separated,  fingers  interlaced. 
Bend  body  forward,  swinging  hands  to  floor  between  feet.  Raise 
bodv,  swinging  hands  up  over  right  shoulder,  at  same  time  twisting 
to  right.     Swing  to  floor.     Same  to  left. 

5.  Hop,  feet  apart,  then  together,  quickly. 

6.  Run  in  place — i.  e.,  without  advancing. 

(a)  With  front  of  thighs  kept  in  same  plane  with  front  of  body, 
heels  striking  buttocks  in  running. 

(6)  With  each  step  in  running,  raise  the  knees  as  high  as  possi- 
ble in  front  of  body. 

The  running  and  hopping  should  be  done  quickly,  and  continued 
long  enough  to  get  the  body  thoroughly  warm. 

Passive  Exercises. — i.  Trunk-rolling.  Patient  in  a  sitting  posi- 
tion, feet  separated  and  fixed.  Grasp  him  by  the  shoulders,  and 
with  a  continuous  movement  bend  the  body  to  the  right,  forward, 
left,  back  to  the  starting  position.  After  the  movement  has  been 
given  several  times,  reverse  the  direction. 

2.  Thigh-rolling.  Patient  in  a  semi-reclining  position.  Grasp 
patient's  foot  with  right  hand,  his  leg  just  below  the  knee  with  left. 
Raise  thigh  and  circumduct  it,  the  knee  describing  as  large  a  circle 
as  possible. 


FLAT-FOOT  543 

Exercises  with  Resistance. —  i.  Reclining  position.  IHcx  and  ex- 
tend thighs. 

2.  Semi-reclining  position,  with  knees  drawn  up.  Abduct  and 
adduct  thighs. 

The  prescription  for  treatment  may  be  arranged  in  this  order: 
active  exercises,  passive  exercises,  exercises  with  resistance,  ending 
with  some  deep-breathing  exercises. 


FLAT-FOOT 

Flat-foot  is  a  condition  in  which  the  ligaments  and  muscles 
of  the  foot  are  abnormally  weak,  and  in  which  the  anterior  posterior 
arch  may  be  partially  or  wholly  depressed  and  flattened. 

The  leg  is  rotated  inward  and  the  foot  everted;  the  weight  of 
the  body  falls  on  the  inner  side  of  the  foot;  the  interior  malleolus 
is  prominent;  the  entire  sole  of  the  foot  rests  on  the  floor;  and 
when  the  feet  are  placed  side  by  side  and  the  toes  and  heels  touch, 
the  natural  concavity  of  the  inner  line  of  the  foot  is  replaced  by  a 
convexity.  The  patient  complains  of  pain  or  weakness,  and  the 
tissues  of  the  sole  are  weak  and  flabby. 

There  are  different  methods  of  examining  the  outlines  of  the 
sole  of  the  foot:  standing  with  the  foot  on  a  plate  of  glass  so  that 
the  sole  of  the  foot  may  be  seen  from  beneath;  smearing  the  sole 
with  vaseHn  and  standing  on  a  piece  of  blotting-paper;  smearing  it 
with  charcoal  and  standing  on  a  piece  of  white  paper,  etc. 

The  patient  should  have  proper  rest.  He  should  frequently 
sit  with  feet  elevated,  and  avoid  exhaustion.  When  standing,  he 
should  occasionally  invert  the  feet,  and,  when  walking,  walk  with 
the  feet  parallel,  as  the  Indians  do,  and  for  short  distances  walk 
on  the  outer  borders  of  the  feet. 

The  feet  should  be  cared  for  each  day,  giving  attention  to  the 
nails  and  to  bathing.  Apply  hot  and  cold  water  alternately,  and  rub 
vigorously  in  order  to  stimulate  the  muscles  and  the  circulation. 

The  feet  should  be  properly  clothed;  the  stockings  should  be 
even,  smooth,  and  loose,  but  should  not  heat  the  feet.  The  shoes 
should  be  broad  enough  to  permit  free  use  of  the  muscles  of  the  feet ; 
the  toe  of  the  shoe  should  point  sHghtly  inward,  and  the  inner  border 
may  be  raised;   the  heels  should  be  low  and  broad. 

The  general  condition  of  the  patient  should  be  carefully  considered, 
his  general  tonicity — for  its  impairment  will  affect  the  condition  of 
the  feet.  Judgment  should  be  used  in  the  care  and  use  of  the  feet 
in  rheumatism,  and  during  and  shortly  after  convalescence  where 
there  is  a  general  relaxation  of  muscles  and  ligaments.  Malnutri- 
tion and  obesity,  if  present,  should  receive  attention  while  the  feet 
are  being  treated. 

In  severe  cases,  in  the  beginning,  the  patient  should  be  kept  en- 


544  GYMNASTIC    THERAPEUTICS 

tircly  off  of  his  feet,  and  given  only  passive  exercises,  massage,  and 
bathing. 

Exercises. —  i.  RecUning  or  semi-recUning  position.  Extend  foot 
against  resistance. 

2.  Reclining  position.  Adduct  and  invert  foot  against  resis- 
tance. 

3.  Reclining  position.  Circumduct  foot  inward,  upward,  and 
outward  with  resistance  applied  to  the  inward  and  upward  motion. 

4.  Standing  position.     Raise  on  toes. 

5.  Standing  position.  Raise  on  toes ;  turn  heels  outward ;  lower 
heels  slowly  to  floor. 

Passive  Exercises. —  i.  With  one  hand  hold  heel  firm,  at  the  same 
time  pressing  on  the  astragalus  with  an  outward,  upward  motion 
of  the  thumb,  while  the  other  hand  adducts,  everts,  and  flexes  the 
foot.     This  may  be  done  under  hot  water  if  the  deformity  is  marked. 

2.  Extension  of  foot. 

3.  Adduction  of  foot. 

Massage. — Deep-kneading,  vibration,  and  clapping  may  be  given 
to  the  foot  and  to  the  muscles  of  the  calf  of  the  leg. 

A  gauze  pad  may  be  placed  under  the  arch,  and  held  by  adhesive 
plaster  or  a  rubber  bandage,  until  a  well-fitted  plate  can  be  made, 
which  should  be  used  for  support  in  the  intervals  between  treatments, 
until  the  muscles  and  ligaments  have  gained  sufficient  strength  to 
hold  the  arch  in  a  normal  position. 


DRUGS  AND  DRUG  DOSAGE 
FOR  INTERNAL  USE 


Drug. 


ACETANILID. 

Not  advised  in  the  treatment  of  chil- 
dren. 
Acid,  Arsenious.     See  Arsenic. 
Acid,  Benzoic.     Benzoic  Acid,  Flowers  of 
Benzoin 

Used  in  cystitis  of  alkaline  type 

Acid,  Gallic. 

Bismuth  Subgallate.     (Dermatol.) 

Used  internally  as  an  intestinal  astrin- 
gent, also  externally, 

Acid,  Hydrochloric,    Dilute.     (Corre- 
sponding   to    31.9%    of    absolute 
HCl.) 
Used  in  chronic  gastritis  with  atony 

of  the  stomach 

Acid,  Lactic. 

Used     in      fermentative     diarrheas. 
Given  best  well  diluted  with  syrup  and 

water  and  at  2-hour  intervals 

Acid,  Phosphoric,  Dilute.     (Containing 
10%  Orthophosphoric  Acid.) 

Used  as  a  stomachic 

Acid,  Salicylic. 

Seldom  used  uncombined. 
Bismuth  Subsalicylate. 

Intestinal  astringent  and  sedative  .  .  . 
Methyl    Salicylate.     (Synthetic    Oil    of 
Wintergreen.) 

Antirheumatic 

Oil  of  Wintergreen.     (Natural.) 

Antirheumatic 

Salol.     (Phenyl-salicylate.) 

Intestinal    antiseptic  and    antirheu- 
matic   

Sodium  Salicylate. 

Antirheumatic 

Aspirin.  (Non-officinal.)  (Acetyl-sali- 
cylic  Acid.) 
Antirheumatic, — a  substitute  for  So- 
dium Salicylate,  being  less  irritating  to 
the  stomach.  Best  given  in  capsules, 
for  it  is  decomposed  by  alkalies  and  by 

moisture 

Acid,  Tannic. 

Used  in  the  form  of: 
Tannalbin.    (Dried  Albuminate  of  Tan- 
nin.) 
Used  as  an  intestinal  astringent  .... 

35  545 


6  Months.    18  Months.    3  Years.       5  Years. 


gr.  1 


gr.  3-5 


gt.  i-* 


gtt.  1-2 

gr.  1 

gt.  1 
gt.  1 

gr.  1 


gr.  1 


gr.  1-2 


gr.  1-2 
gr.5 

gt.  1 

gt.  1 
gtt.  2-3 

gr.  1-2 

gtt.  2-3 
gtt.  2-3 

gr.  1-2 
gr.  1-2 


gr.  1-2 


gr.  1-2 


gr.2 
gr.  10 

gtt.  2 

gtt.  2 
gtt.  5 

gr.2 

gtt.  3 
gtt.  3 

gr.2 
gr.  2-3 


gr.  2-3 


gr.  2-3 


gr.  3-5 
gr.  10 

gtt.  3-5 

gtt.  3-5 
gtt.  10 

gr.  3-5 

gtt.  3-5 
gtt.  3-5 

gr.  3 
gr.  3-5 

gr.  3-5 
gr.  3-5 


546 


DRUGS   AND    DRUG   DOSAGE 


DRUGS  AND  DRUG   DOSAGE— FOR  INTERNAL  VSU— (Continued) 


Drug. 


Acid,  Tannic  {Continued). 
Tannigen.      (Acetyl-tannin.) 

Used  as  an  intestinal  astringent  .... 
Also  by  rectum :   1  %  solution  of  Tannic 
Acid  in  an  enema,  for  dysentery  or  col- 
itis. 
Acid,  Tartaric. 

Seldom  used  except  as  one  of  its  salts. 

Potassium  Bitartrate.   (Cream  of  Tartar.) 

Diuretic,    refrigerant,  and    aperient. 

Used  as  an  ingredient  of  diuretic  drinks. 

To  one  pint  of  water  to  be  drunk  in 

twenty-four  hours,  is  added : 

Potassium  and  Antimony  Tartrate. 
(Tartar  Emetic.) 
Used  as  an  expectorant.  Its  action 
is  too  violent  for  use  as  an  emetic. 
Best  given  alone  or  with  Ipecac  in  a 
tablet  or  in  a  mixture  with  a  simple 
elixir. 

May     cause     severe    gastro-enteritis 

in  too  large  doses 

Potassium  and  Sodium  Tartrate.      (Ro- 
chelle  Salt.) 

Laxative 

Aconite.     (Aconitum  Napellus.)     (Root 
contains  0.5%  Aconitin.) 
Tincture  of  Aconite  Root  (10%). 

Used  in  a  beginning  fever  as  a  circu- 
latory sedative  and  an  analgesic 

Alcohol.      (Ethyl     Alcohol,    Spirits     of 
Wine.) 
Best  given  as  Whisky  or  Brandy  for 
a  general  stimulant  toward  the  end  of 
an  illness  or  as  a  last  resort. 
Brandy.      (Spiritus    Vini    Gallici,  con- 
taining 39-47%  alcohol  by  weight.) 

Whisky.      (vSpiritus  Frumenti,  contain- 
ing 44-50%  alcohol  by  weight.) .  . 

Sherry  Wine.      (Vinum  Xerici,  contain- 
ing Alcohol  15-20%  by  weight.) . . . 

Aloes. 

Not    advised    in    the    treatment  of 
children. 
Alum. 

Not    advised    in    the    treatment    of 
children. 
Ammonium. 

Ammonium  Bromid.     See  Bromin. 
Ammonium  Chlorid.     (Sal  Ammoniac.) 
Stimulating  expectorant;  best  given 
dissolved  in  half  an  ounce  of  water 


6  Months.   18  Months.    3  Years.   |   5  Years 


gr.  1-2 


gr.  15 
gt.  i 

gtt.  5-10 
gtt.  5-10 


gr.  i 


gr.  1-2 


gr.  ik 
gr.  30 

gt.  i 


gtt.  10- 
20 

gtt.  10- 
20 

gtt.  30 


gr. 


i-* 


gr.  2-3 


gr.  tU 
51-2 

gt.  1 


gtt.  20- 
30 

gtt.  20- 
30 

gtt.  45- 

51 


gr.  3-5 


gr.  1 


54 


gr.  lU 
53-4 

gtt.  1-2 


gtt.  30- 
40 

gtt.  30- 
40 


51-2 


gr.  1-2 


FOR   INTERNAL   USE  547 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSE— (Continued) 


Ammonium  {Continued). 

Ammonium  Carbonate.     (Sal  Volatile.) 
Stimulating  expectorant;  best  given 

dissolved  in  half  an  ounce  of  water 

Solution  of  A  m  m oniu  m  A  cetate.     (Liquor 
Ammonii    Acetatis   or    Spirits    of 
Mindererus.) 
Stimulating  expectorant ;  best  given 
well  diluted  in  carbonic  water. 

Used  also  as  a  diuretic,  antipyretic, 

and  diaphoretic 

Aromatic  Spirits  of  Ammonia.     (Spiri- 

tus  Ammonii  Aromaticus.) 

Used  as   a   stimulating  expectorant, 

volatile    stimulant,    carminative,    and 

antispasmodic.     Best  given  well  diluted 

with  water 

Antimony. 

Antimony     and     Potassium      Tartrate. 
(Tartar  Emetic.)     See  under  y4 c/</, 
Tartaric. 
Antipyrin. 

Analgesic  and  sedative  in  pertussis 
and  laryngitis. 

Best  given  alone  in  powder  form,  or 

with  Sodium  Bromid  in  solution 

Antitoxin.      See    Serum,    Antidiphther- 

itic. 
Apomorphin. 

Not    advised    in    the    treatment   of 
children. 
Arsenic. 

Arsenious  Acid.     (Arsenic  Trioxid    or 
White  Arsenic.) 
Used      in     anemia,      malaria,      and 

chorea. 
Administered  either  in  solution  (see 
Fowler's   Solution)   or   in  tablets  with 
other  ingredients. 

In  large  doses  it  is  an  irritant  poison 
causing  puffiness  of  the  eyes  and  gas- 
tro-enteritis,  both  of  which  are  signs  of 
an  overdose. 

Cannot  be  given  with  astringents, 
tinctures,  or  decoctions,  or  with  solu- 
tions of  Iron. 

Antidotes  are  Hydrated  Iron  with 
Magnesia,  egg-albumen,  and  emetics. 

Given  three  times  a  day 

Fowler's     Solution.     (Liquor     Potassii 
Arsenitis.) 
Uses,  action,  and  antidotes  are  the 
same  as  Arsenious  Acid. 

Best  given  in  water  into  which  it  is 
freshly  dropped 


6  Months.  18  Months.    3  Years.      5  Years. 


gr.  i-i 


gtt.  3 


gr.  i 


gr.  i-1 


oM 


gtt.  3-5 


1-U 


gt.  i 


gr.  2i<i 


gt.  1 


gr.  1 


31 


gtt.  5 


gr. 


gr-Ti^ 


gtt.  2 


gr.  1-2 


52 


gtt.  5-10 


gr.  3 


gr-  T¥o 


gtt.  2-5 


548  DRUGS   AND    DRUG    DOSAGE 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  HSU— (Continued) 


ASAFETIDA. 

Emulsion  of  Asafetida.     (Milk  of  Asa- 
fetida.) 

Used  chiefly  as  an  ingredient  of 
enemata,  especially  in  excessive  tym- 
panites.    To  8  ounces  of  diluent 

AsPiDiUM.     (Male-fern.) 
Oleoresin  of  Male-fern. 

Teniafuge. 

Best  given  in  emulsion  or  in  cap- 
sules   


Aspirin.     See  under  Acid,  Salicylic. 
Atropin.     See  under  Belladonna. 
Basham's  Mixture.     See  under  Iron. 
Belladona.      (From   the    leaves    of   the 
Atropa       Belladonna,      containing 
0.35%  of  alkaloid.) 
Atropin.     (Alkaloid  of  Belladonna.) 
Respiratory   stimulant,   antihidrotic. 
Used   as   a   stimulant,  a    mydriatic, 

and  for  the  cure  of  enuresis 

Tincture  of  Belladonna  (10%  leaves). 

Uses  similar  to  Atropin 

Belladonna  Leaves.     (Asthma  Powder.) 
Used  occasionally  with  the  leaves  of 
Conium   and  Stramonium,  and    Potas- 
sium Nitrate  (Saltpetre)   to  relieve  at- 
tacks of  asthma.     To  be  burned  in  a 
metallic  receptacle. 
Benzoic  Acid.     See  Acid,  Benzoic. 
Bichlorid    of     Mercury.     See     under 

Mercury. 
Bismuth. 

Bismuth  Subcarbonate. 

Intestinal  astringent  and  sedative.  .  . 
Bismuth  Subgallate.     (Dermatol.) 

Intestinal    astringent    and  sedative. 

Used  also  externally 

Bismuth  Subnitrate. 

Intestinal  astringent  and  sedative . .  . 

Bismuth  Subsalicylate.     See  under  Acid, 
Salicylic. 
Blaud's  Pill.     See  under  Iron. 
Borax.     (Sodium    Borate.)      See  under 

Sodium. 
Brandy.     See  under  Alcohol. 
Bromin. 

Used  only  in  the  form  of  its  salts. 
Ammonium  Bromid. 

Sedative.  Used  in  laryngismus, 
pertussis,  asthmatic  bronchitis,  and 
sleeplessness. 

Best  given  well  diluted  with  water. . . 


6  Months.  18  Months.    3  Years.       5  Years. 


gt.  M 


gr.  10 

gr.  3-5 
gr.  5-10 


gr.  1-3 


gr.  3^ 
gt.  1 


gr.  10 

gr.  5 
gr.  10 


gr.  2-4 


31 


gr.  10- 
15 


gr.  T^o 
gtt.  1-2 


gr.  10 


gr.  5-10 

gr.  10- 
15 


gr.  3-5 


31 


gr.  20- 
30 


gr.  ih 
gt.  3-5 


gr.  20 

gr.  10 
gr.  20 


gr.  5-8 


FOR   INTERNAIv   USE  549 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  USE— (Continued) 


Drug. 

Dose. 

6  Months. 

18  Months 

3  Years. 

5  Years. 

Bromin  (Continued). 

Potassium  Bromid. 

Used  same  as  the  Ammonium  salt, 

but  it  is  more  depressing 

Sodium  Bromid. 

gr.  1-3 

gr.  2-4 

gr.  3-5 

gr.  5-8 

Used  same  as  the  above.     It  is  mid- 

way between  the  Ammonium  and  the 

Potassium  salts  in  its  depressant  action. 
Strontium  Bromid. 

gr.  1-3 

gr.  2-4 

gr.  3-5 

gr.  5-8 

Used  same  as  the  above 

gr.  1-3 

gr.  2-4 

gr.  3-5 

gr.  5-8 

Brown  Mixture.     See  under  Liquorice. 

Caffein. 

Citrate  of  Caffein  (50%  Caffein). 

General  stimulant  and  diuretic 

Calcium. 

gr.  * 

gr.  i-1 

gr.  1 

gr.  1-2 

Calcium  Chlorid. 

Of   some  benefit   in  hemophilia  and 

purpura   hemorrhagica 

gr.  i 

gr.  1 

gr.  1-2 

gr.2 

Calcium  Sulphid. 

Antipustulant 

gr.  aV 

gr.  ,V 

gr.  ,\ 

/v..           1 

Prepared  Chalk. 

gr-  To 

Antacid 

gr.2 

gr.  3 

gr.  5 

gr.  5-8 

Compound    Chalk    Mixture.     (Mistura 

Cretae  Composita.) 

20%  Chalk  Powder,  40%  Cinnamon- 

water. 

Antacid.     Every  2  hours 

T  1 

"Z  1 

oH 

32 

Calomel.     See  under  Mercury. 

0  1 

0  i 

Camphor. 

Powdered  Camphor. 

Used  in  coryza.     Every  2  hours 

gr.  tV 

gr.  ^ 

gr.  i 

gr.  i 

Spirits  of  Camphor  (10%,  in  Alcohol). 

Stimulant,  anodyne,  carminative .  .  . 

gtt.  3 

gtt.  5 

gtt.  5-10 

gtt.  10 

Water  of  Camphor.     (Aqua  Camphorae.) 

(Contains  0.8%  of  Camphor.) 

Used  as  a  vehicle. 

Cantharides. 

Used  best  in : 

Tincture  of  Cantharides  (10%). 

Useful     in    cystitis    and    functional 

albuminuria 

gt.  i-i 

gt.  i 

Capsicum. 

Used  best  in: 

Tincture  of  Capsicum  (10%). 

Used    as    a    carminative  and  stom- 

achic.     Best    given    well    diluted    in 

water 

(Tf        1 

gtt.  2-3 

gtt.  3-5 

Cardamom. 

g"-.      i 

Used  best  as : 

Tincture  of  Cardamom. 

Used  as  a  carminative 

gtt.  5 

gtt.  10 

gtt.  15 

gtt.  20 

Cascara  Sagrada.     (Bark  of  the  Rham- 

nus   Purshiana.) 

Extract  of  Cascara  Sagrada. 

(Four  times  the  strength  of  the  bark.) 

Tonic  laxative 

.gr.  * 

gr.  1-2 

gr.  3-5 

550  DRUGS   AND    DRUG    DOSAGE 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSU— {Continued) 


Drug. 


Cascara  Sagrada  {Continued). 

Fluidextract       of       Cascara      Sagrada. 

(Aromatic.)     (1  c.c.  =  1  gm.  bark.) 

The    active    principles   are  retained, 

but  the  bitter  principles  are  eliminated. 

Tonic   laxative 


Castor  Oil.     (Oleum  Ricini.) 

(Expressed  from  the  seeds  of  Ricinus 
Communis.) 

Bland  oil  and  cathartic. 

Given  usually  for  one  dose 

Cerium  Oxalate. 

Sedative  in  vomiting 

Chalk.     See  Calcium. 
Chloral  Hydrate. 

Sedative,    hypnotic,    and     antispas- 
modic. 

Best  given  in  some  Inland   fluid    by 

rectum 

Chloroform. 

Given  internally  as : 
Spirits  of  Chloroform.     (Chloric  Ether.) 
(6%  Chloroform.) 
Carminative,  antispasmodic,  and  sed- 
ative   


Water    of   Chloroform.     (Aqua   Chloro- 
formi.)     (0.5%  Chloroform.) 

Vehicle  and  carminative 

Cinchona.     See  under  Ouinin. 
CocAiN,  or: 

Cocain  Hydrochlorid. 

Local  anesthetic  by  hypodermic 
injection. 

Used  in  0.2%  to  4%  strength.  But 
seldom  used  for  local  anesthesia  in 
children.     Used     by     the     mouth     in 

obstinate  vomiting 

CoDEiN.     See  Opium. 
CoD-LivER  Oil.     (Oleum  Morrhuae.) 
Fixed  oil  from  fresh  cod's  hvers. 
Alterative  and  tonic. 
Given  three  times  a  day 


Dose 


6  Months.  18  Months.    3  Years.       5  Years, 


Corrosive    Sublimate.      See    Corrosive 

Chlorid  of  Mercury. 
Cream    of    Tartar.     See    under   Acid, 

Tartaric. 
Creosote.     (Beechwood  Creosote.) 

Tonic,  alterative,  and  antitubercu- 
lar. 

Best  given  in  an  emulsion  with 
Cinnamon-water,  three  times  a  day 
after   meals 


gtt.  15 


51 

gr.2 


jtt.  2-3 


gtt.  30- 
45 


52 

gr.  2-3 


gr.  1 


rtt.  3-5 


5*-2 


gtt.  1 

15 


gt.  * 


gr-  riiT 


gtt.  15- 
20 


51 


gr.  3 


gr.  li 


gtt.  5-55 


52-3 


gr.  ?V 


gtt.  20- 
30 


gtt. 


1-2 


54 
gr.  3-5 


gr.2 


gtt.  15- 
20 


54 


gr.^ 


5i-i 


gtt.  2-3 


gtt.  3-5 


FOR    INTERNAL    USE  551 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSE— (Continued) 


Druc 


Creosote  (Continued) . 

Creosotal.  (Carbonate  of  Creosote — 
92%  Creosote.) 
Is  preferable  to  Creosote  because 
it  has  little  odor,  a  inore  agreeable 
taste,  and  is  better  borne  by  the  stom- 
ach   

Dermatol.     (Bismuth    Subgallate.)     See 

under  Bismuth. 
Digitalis.     (From  the  leaves  of  Digitalis 
Purpurea.) 
Heart     stimulant    and     tonic;     also 
diuretic. 

Best  given  by  mouth  in  the  form 
of  the  Tincture  and  hypodermically 
either  as  the  Tincture  or  as  Digitalin. 

Tincture  of  Digitalis  (10%  leaves) 

Infusion  of  Digitalis  (66  gm.   =   1  gm. 

leaves) 

Digitalin  (ten  times  strength  of  leaves). 
Diphtheria     Antitoxin.      See     Serum, 

A  nti-diphtheritic. 
Dover's  Powder.     See  under  Opium. 
Epsom  Salt.     See  under  Mae,ucsium. 
Ergot.     (From    the    sclerolium    of    the 
Claviceps  Purpurea  of  Rye.) 
Hemostatic,    heart    and   circulatory 
stimulant. 
Fluidextract     of     Ergot     (1  c.c.  =  l  gm. 

Ergot) 

Eriodyctyon.     See  Verba  Santa. 
Ether. 

Used  internally  as : 
Compound     Spirits    of     Ether.     (Hoff- 
mann's   Anodyne,    32.5%  Ether.) 
Anodyne,       carminative,      antispas- 
modic, and  stimulant. 

Best  given  well  diluted  with  water. . . 

Spirits      of      Nitrous      Ether.     (Sweet 

Spirit  of  Niter,  4%  Ethyl  Nitrite.) 

Used     as     a    diaphoretic,     diuretic 

and  carminative. 

It  is  volatile  and  explosive  and 
incompatible  with  many  drugs.     Best 

given  alone  or  in  a  simple  elixir 

Fel  Bovis.     See  Ox-gall. 

Ferrum.     See  Iroti. 

Fowler's  Solution.     See  Arsenic. 

Gallic  Acid.     See  Acid,  Gallic. 

Gentian. 

Extract  of  Gentian. 

Stomachic  and  bitter  tonic. 

Given  three  times  a  day 

Glauber's     Salt.     (Sodium    Sulphate.) 
See  under  Sodium. 


Dosii. 


Months.   18  Months 


gt.  ^ 


gt.     h 
gr.  jh 


gtt.  2-3 


gtt.  2 


gtt.  2-3 


gtt.  2 


gt.     1 
gr.  ^U 


gtt.  5 


gtt.  3-5 


gtt.  3-5 


Years.      5  Years. 


gtt.  2-3 


gtt.  3-5 


gtt.  1-2    gtt.  2-3 

oi-1        151-3 
gr.  ih      gr.  jU 


gtt.  5-8    gtt.  10- 
15 


tt.  5        gtt.  5-10 


rU.  5 


gr.  i-i 


gtt.  5-10 


gr.  *-l 


552 


DRUGS   AND    DRUG    DOSAGE 


DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSU— (Continued) 


Drug. 

Dose. 

6  Months. 

18  Months. 

3  Years. 

5  Years. 

Glonoin.     See  Nitroglycerin. 

Glycerin. 

Used    chiefly  as    a    demulcent   base 

and  a  vehicle  for  other  drugs. 

Glycyrrhiza.     See  Liquorice. 

HexamEThylenamin.     Official  name  for 

the  proprietary  Urotropin,  q.  v. 

Hoffmann's  Anodyne.     See  under  Ether. 

Hydrargyrum.     See  Mercury. 

Hyoscyamus. 

Tincture  of  Hyoscyamus. 

Sedative  and  antispasmodic. 

Given  every  two  hours 

gt.  ^-1 

o^tt     1-2 

gtt.  3 

gtt.  3-5 

Liquor    Ferri    et    Ammonii    Acetatis. 

j,LL.     1      z. 

(Basham's      Mixture — Solution       of 

Iron    and    Ammonium    Acetate — 10% 

metallic  Iron) 

gtt.  15- 

ol 

gtt.  20- 

Ovoferrin.     (Proprietary  Organic  Iron.) 

gtt."  5 

gtt.'  10 

20 

30 

Pyrophosphate  of  Iron  (10%  of  metallic 

Iron)  

gr.  1-2 

gr.  2-3 

Syrup  of  the  lodid  of  .Iron  (5%,  Ferrous 

lodid) 

gtt.  3 

gtt.  6 

gtt.  10 

gtt.  20- 
30 

Tincture  of  the  Chlorid  of  Iron. 

(35%  of  Ferric  Chlorid  and  must  be 

at  least  one  year  old.) 

gt.  1 

gtt.  3 

gtt.  5 

gtt.  10- 
15 

Jalap. 

Powdered  Jalap.     (Contains  8  %  Resin . ) 

Hydragog  cathartic  and  diuretic 

gr.  2 

gr.  3 

Lactic  Acid.     See  Acid,  Lactic. 

Liquorice. 

Compound  Liquorice  Mixture.     (Brown 

Mixture^  12%  Paregoric.) 

Sedative  expectorant  mixture. 

Given  at  two-hour  intervals 

gtt.  15 

gtt.  20 

gtt.  30- 
40 

gtt.  40- 

51 

Compound  Liquorice  Poivder. 

Laxative 

gr.  10 

gr.  10- 
20 

gr.  30 

gr.40- 

31 

Magnesium. 

Magnesium  Carbonate. 

Antacid  and  laxative 

gr.  5-10 

gr.  20 

gr.  30- 

gr.  40- 

40 

31 

Magnesium  Citrate,  Solution  of.     (Liq- 

uor Magnesii  Citratis.) 

Laxative.     For  one  dose 

52 

§2-4 

Magnesium  Oxid.    (Calcined  Magnesia.) 

Antacid  and  laxative 

gr.  5-10 

gr.  10- 

gr.  20- 

gr.  30- 

20 

30 

40 

Magnesium    Sulphate.     (Epsom    Salt.) 

Laxative.     To    be    given  every   two 

hours  and  discontinued  when  the  de- 

sired effect  has  been  produced 

gr.  10-15 

gr.  20 

gr.  20-30 

3*-i 

FOR    INTERNAL    USE  553 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSZ— (Continued) 


Drug. 


Male-fern.     See  Aspidium. 
Mentha  Piperita.     See  Peppermint. 
Mentha  Viridis.     See  Spearmint. 
Mercury. 

Mass   of   Mercury.     (Blue  Mass — 35% 
Mercury.) 
Cathartic  and  antisyphilitic. 

Used  once  a  day 

Corrosive  Chlorid  of  Mercury.     (Bichlo- 
rid  of   Mercury  or  Corrosive  Sub- 
limate.) 
Antisyphilitic. 

Given  three  times  a  day 

Mild   Chlorid   of  Mercury.      (Calomel.) 
Cathartic,    cholagog,     antisyphilitic. 

At  30-minute  intervals 

At  one-hour  intervals 

Rarely  necessary  to  give  more  than 
one  grain  for  laxative  effect. 
Red     lodid     of    Mercury.      (Biniodid.) 
Antisyphilitic. 

Given  three  times  a  day 

Alercury  with  Chalk.     (Gray  Powder.) 
(38%  Mercury.) 
Intestinal    antiseptic,   cholagog,  and 
antisyphilitic. 

At  one-hour  intervals — total  gr.  1 . . . 

At  one-hour  intervals — total  gr.  2 . . . 

Methyl    Salicylate.     See  under    Acid, 

Salicylic. 
MinderErus,     Spirits    of.     See    under 

Ammonium. 
MoRPHiN.     See  under  Opium. 
Myrrh. 

Tincture  of  Myrrh  (20%). 

Used  as  a  mouth-wash  diluted  with 
water. 
Niter.     See  under  Ether,  Sweet  Spirits  of 

Niter. 
Nitroglycerin.     (Glonoin,  Glyceryl  Tri- 
nitrate.) 

Vaso-dilator 

Spirits  of  Glyceryl  Trinitrate,  or  Spirits 
of    Glonoin,    old     U.    S.    P.    (1% 

alcoholic   solution.) 

Nux    Vomica.     (From    Strychnos    Nux 
Vomica.) 
Tincture  of  Nux  Vomica  (1%  Strych- 
nin). 

Stomachic  and  stimulant 

Strychnin.     (Alkaloid  of  Nux  Vomica.) 
General    stimulant,    well    borne    by 
children. 

Every  two  or  three  hours 


Dose. 


6  Months.  18  Months.    3  Years.      5  Years. 


gr-  T(T 

gr-  xio 
gr.  1 


gr.  T^o 
gt.i 

gt.  ^ 


gr-  i-To- 

20T) 


gr-  jho 
gr-  i 

gr-  1^0 
gr   i 


gr.  3(Jo 
gt.  i 

gt.  1 
gr.  jh 


gr- 


gr-  lU 


gr.  i 


gr-i 


.  h 


jtt.  1-2 


gr-  TUo 


gr.  1-2 

gr-  yV 
gr.'i 

gr.2'W5 
gr-i 


gr-iio 
gt.  1 

gtt.  2-4 
gr.  T50 


554  DRUGS   AND    DRUG    DOSAGE 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  USU— (Continued) 


Dose. 


Drug 


OivEUM  Gaultherium.  (Oil  of  Win- 
ter-green.) See  under  Acid,  Sal- 
icylic. 

Oleum  Morrhu^.     See  Cod-liver  Oil. 

Oleum  Oliv.b.     See  Olive  Oil. 

Oleum  Ricini.     See  Castor  Oil. 

Olive  Oil. 

Laxative  and  nutrient 

Used    at   night   by   rectum   for    the 

cure  of  constipation 

Opium. 

Sedative,  anodyne,  hypnotic. 
Tincture  of    Deodorized  Opium  (10%). 

Used  in  3-  to  10-drop  doses  in  ene- 
mata  as  a  sedative  for  children  under 
five  years  of  age. 

Camphorated  Tincture  of  Opium.  (Par- 
egoric— 0.4%  Opium.) 

Sedative  and  analgesic 

Powder  of  Ipecac  and  Opium.  (Dover's 
Powder — 10%  each  of  Ipecac  and 
Opium.) 

Sedative 

Morphin.     (Alkaloid  of  Opium.) 

Not  well  borne  by  children  and  best 

given  hypodermatically 

Codein.     (Methylmorphin.) 

As  sulphate  or  phosphate 

Heroin.     (Diacetylmorphin.) 
As  hydrochlorid. 

Bronchial  sedative 

Orange-juice.     (Citrus  Aurantium.) 

Antiscorbutic 

Ox-gall.     (Fel    Bovis — Fresh   Ox-bile.) 
Used    as    a    laxative   in   enemata — 
05-  5  1  to  a  pint  of  water. 
Paregoric.     Camphorated     Tincture     of 

Opium.     See  under  Opium. 
PEPo.     See  Pumpkin  Seed. 
Peppermint. 

Aqiia    Mentha     Piperitce — Peppermint 
Water.       (0.2%    Oil    of    Pepper- 
mint.) 
Carminative,  sedative,  corrective  and 

vehicle 

Pepsin. 

Powdered  Pepsin 

Essence  of  Pepsin 

Phenacetin.     (Acetphenetidin.) 

Antipyretic  and  analgesic 

Phosphoric    Acid.        See    Acid,     Phos- 
phoric. 


6  Months.  18  Months.!   3  Years. 


gtt.   15 


ol 


gtt.  3-5 

gr.  i-i 
gr.  ik 

5i 


51 

gr.  1 
gtt.  20 


gr.  ^ 


gtt.  15- 
30 


gtt.  10 


gr.  i-l 

gr-  T^o 
gr.  2V 


51-2 

gr.  1-2 

gtt.  30- 

40 

gr.  1 


gtt.  30- 
51 

52 


gtt.  15- 
20 


gr.  1-U 

gr.  io 
gr.  tV 

gr.  -io 


53 

gr.  2-3 

gtt.  40- 

51 

gr.  U 


gtt.  20- 
30 


gr.  2-3 

gr.  is 
gr.i 

gr.  io 
ol 


54 


gr.  3 
51 


gr.  2 


FOR   INTERNAI.    USE  555 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  USE— (Continued) 

Dose. 


Drug. 


Phosphorus. 

Oleum  Phosphoratum  ( 1  %  in  Almond  Oil) 

Alterative gt.  i 

Syrup  of  Hypo  phosphites. 

(Calcium'  4.5%,  Sodium  and  Potas 

slum  each  1.5%.) 5i 

PiLOCARPIN. 

Not    advised    in    the    treatment   of 
children. 
Potassium. 

Potassium  Acetate. 

Diuretic,  refrigerant,  and  alterative. .     gr.  1-2 
Potassium  Bicarbonate. 

Should  not  be  given  to  children  on 
account  of  its  disagreeable  taste. 
Potassium  Bitartrate.     (Cream  of  Tar- 
tar.)    See  under  Acid,  Tartaric. 
Potassium  Bromid.    See  under  Bromin. 
Potassium  Citrate. 

Diaphoretic  and  diuretic. 

Used  in  acute  bronchitis gr.  ^- 

Potassium  Chlorate. 

Astringent  and  antisialogog. 

Used    in    stomatitis  of    every  type 

in  tonsillitis  and  angina gr. 

Potassium  lodid. 

Antispasmodic  and  antisyphihtic  .  .      gr. 
Potassium       and      Sodium      Tartrate. 
(Rochelle  Salt.)     See  under  Acid, 
Tartaric. 
Prunus  ViRGiNiANA.     See  Wild  Cherry. 
Pumpkin  Seed.     Pepo. 

Teniafuge.     Best  given  in  an  emul- 
sion ;  average  dose    5 1  ■ 
Quassia. 

Infusion  of  Quassia. 
Vermifuge. 

An  extemporaneous  infusion  is  made 
by  adding  1  or  2  oz.  of  Quassia  chips 
to  a  pint  of  water.  This  is  injected 
high  up  into  the  bowel. 

Used    particularly    to    destroy    the 
Oxyuris  vermicularis. 
QuiNiN.      (Alkaloid  of  Cinchona.) 

Bisulphatc  of  Onimn i  gr 

Sulphate  of  Oiiiiiin gr 

Tincture  of  Cinchona 


6  Months.  18  Months.    3  Years.      5  Years, 


All     these     are     bitter    tonics    and 
antiperiodics. 
Rhamnus  Purshiana.     See  Cascara  Sa- 

grada. 
Rhubarb. 

Powdered  Rhubarb. 

Laxative 


gt.  1 


31 


gr. 


2-3 


gtt.  li 


31 


gr.  3 


gr.  1-2 


gr.  1-2 


gr.  1-2 


gr. 


2-3 


2-3 


gr.  1- 
gr.  1- 
gtt.  5-10 


gr.  2-3 


gr.  2-3 
gr.  2-3 
gtt.  15 


gtt.  2-4 
31-2 

gr.  5 


gr.  4 

gr.3 
gr.  3 


gr.  3-4 

gr.  3-4 

gtt.  20- 

30 


556  DRUGS   AND    DRUG    DOSAGE 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  USH— (Continued) 


Rhubarb  {Continued). 

Aromatic  Syrup  of  Rhubarb. 

Laxative  and  flavoring  medium .  .  .  .  , 
Mixture  of  Rhubarb  and  Soda. 

Corrective  and  laxative. 
I^.  Pulveris  rhei 

Sodii  bicarbonatis aa  gr.  48 

Syrupi  rhei  aromatici o  1 

AquEe q.  s.  ad  o2 

M. 

Sig. — One  to  three  doses  daily 

RocHELLE  Salt.     See  under  Acid,   Tar- 
taric. 
Saccharin.     (Benzosulphinidum.) 

Substitute  for  sugar,  but  200  times 
sweeter. 

For  8  oz.  of  food,  ^-1  grain  is  suffi- 
cient. 
Saccharose.     See  Sugar. 
Salicylic  Acid.     See  Acid,  Salicylic. 
Salol.     See  under  Acid,  Salicylic. 
Santonin.      (Anhydrid     of     Santoninic 
Acid.) 
Vermifuge,  for  round-worms  partic- 
ularly  

Senna. 

Cathartic.     Best  given  as  Compound 
Liquorice    Powder,  of  which  it  is  an 
ingredient,  q.  v. 
Serum     AntidiphTheriticum.       (Diph- 
theria Antitoxin.) 
For  immunization: 

1000  to  2000  units. 
In  faucial  diphtheria: 

3000  to    5000   units   and    repeat    in 
8  hours  if  required. 
In  laryngeal  diphtheria : 

5000  units  and  repeat  in  8  hours  if 
required. 

The  repetition  of  the  doses  of 
Antitoxin  is  discontinued  only 
when  the  case  ceases  to  require  the 
serum. 

The  dosage  is  independent  of  the 
age  of  the  patient. 

SODIU.M. 

Sodium  Benzoate. 

Antiseptic,  antipyretic,  and  anti- 
rheumatic. 

Used  in  cystitis  with  alkaline  fermen- 
tation to  acidifv  the  urine,  which  it 
does    by    the    hberation   of    hippuric 

acid 

Sodium  Bicarbonate. 

Antacid,  antirheumatic 


Months.   18  Months.!   3  Years.       5  Years. 


51 


oi 


gr.  i 


gr.  1 
gr.  1-2 


52 


52 


gr.  1 


gr.  1-2 
gr.  2 


53 


53 


gr.  1-2 


gr.  2 
gr.  3 


34 


54 


gr.  2 


gr.  3 
gr.  5 


FOR   INTERNAL    USE  557 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSB— (Continued) 


Sodium  (Continued). 

Sodium  Borate.     (Borax.) 

Antiseptic  and  astringent. 

Used  as  a  gargle  and  mouth-wash 
in  angina  and  stomatitis — ol  to  58 
of  water. 

Sodium  Broynid.     See  under  Bromm. 
Sodium  lodid. 

Uses  and   doses  the  same  as  Potas- 
sium lodid,  q.v. 
Sodium  Phosphate. 

Laxative  and  cholagog 

Sodium   Sulphate.     (Glauber's   Salt.) 

Cathartic. 

Used  in  intestinal  infection  of  mac- 
tive  type 


18  Months.    3  Years. 


gr 


5-10 


Sodium    Salicylate.     See    under   Acid, 
Salicylic. 
Spearmint.     (Mentha  Viridis.) 

Water   of   Spearmint.     (Aqua   Menthae 

Viridis— 0.2%    Oil  of  Spearmint.) 

Carminative,      sedative,      corrective, 

and  vehicle 

Strontium. 

Strontium  Bromid.     See  under  Bromm. 
Strophanthus.  . 

Tincture  of  Strophanthus  (11%  m  New 
Pharmacopeia,    or     twice     former 
strength). 
Cardiac     tonic     and    dmretic.     Pre- 
ferred to  Digitalis  in  the  treatment  of 

children  because  better  borne. 

Strychnin.     See  under  Nux  Vomica. 
Sugar.     (Cane-sugar    or     Saccharose.)  _ 
Sweetening   agent.     May  be   substi- 
tuted   for    Lactose    in   the  adaptation 
of  cow's  milk  for  infant-feeding. 
I  level  tablespoonful  equals  i  oz. 
Sugar  of  Milk.     (Lactose.) 

Used  as  an  excipient  and  in  the 
adaptation  of  cow's  milk  for  infant- 
feeding. 

1  level  tablespoonful  equals  J  oz. 
Sulphonal. 

Not    advised    in    the    treatment    of 
children. 
Sulphur. 

Precipitated  Sulphur,  or   Milk   of  Sul- 
phur. 
Laxative  and  alterative.     Given  usu- 
ally in  syrups  or  other  heavy  vehicles.  . 
Used    also    as    a    reducing    agent  in 
Bismuth  mixtures  when  the  stools  do 
not  become  dark  colored  (see  p.  201) 


gr.  15- 
30 


51 


gr.  10-15 


gr.  30- 

45 


52 


gr.  15-20 


gr.  40- 
51 


53 


gt.  1 


gr.  20-30 


51 


54 


gtt.  1-2 


gr. 


gr- 


gr 


5-10 


gtt.  2 


gtt.  2-3 


gr. 


15-30 


gr.  1 


gr. 


51 


gr.  1 


558  DRUGS   AND   DRUG    DOSAGE 

DRUGS  AND  DRUG  DOSAGE— FOR  INTERNAL  VSU— (Continued) 


Dose. 

6  Months. 

18  Months. 

3  Years. 

5  Years. 

Tannalbin.     See  under  Acid,  Tannic. 

Tannigen.     See  under  Acid,  Tannic. 

Tartar  Emetic.     See   under  Acid,   Tar- 

taric. 

Tartaric  Acid.     See  Acid,  Tartaric. 

Terebene. 

Stimulating    expectorant   and    anti- 

septic. . . 

gt.  1 

gtt.  1-2 

gtt.  2 

Terpin  Hydrate. 

Expectorant  and  antiseptic. 

Used  in  subacute  and  chronic  bron- 

chitis   

gr.  i 

gr.* 

Trional. 

Not    advised    in    the    treatment   of 

children.                                            ♦ 

Urotropin.     (Trade  name  for  Hexame- 

thylenamine.) 

Urinary  antiseptic  and  sedative 

gr.i 

gr.  1 

gr.  1-2 

gr.  2-5 

Whisky.     See  under  Alcohol. 

AViLD  Cherry. 

Syrup      of      Wild     Cherry.      (Syrupus 

Pruni  Virginiani.) 

Bronchial  sedative  and  vehicle. 

oi 

31 

DRUGS  FOR  EXTERNAL  USE 

Acid,  Boric. 

Antiseptic  of  mild  grade.     4%  is  a  saturated  solution. 

Used  both  in  solution  and  in  ointments. 

In  the  form  of  scales  it  is  most  soluble  and  most  convenient. 
Acid,  Carbolic     See  Phenol. 
Acid,  Chromic     (Chromic  Trioxid.) 

A  very  strong  caustic  and  astringent,  used  as  a  substitute  for  Nitrate 
of  Silver. 
Acid,  Nitric  (68%  pure  acid). 

Used  as  a  caustic. 
Acid,  S.^licylic 

Used  in  lotions  or  in  ointments,  1%  to  3%,  for  skin  affections. 
Acid,  Tannic 

Astringent. 

Used  in  1%  solution  in  dysentery;  as  an  ingredient  of  suppositories  for 
hemorrhoids.     See  also  Glycerite  of  Tannin  under  Glycerin. 
Adrenalin.     (Trade  name  for  the  active  principle  of  the  Adrenal  Gland.) 

Used  in  a  solution  in  the  strength  of  1  part  to  1000  of  normal  saline  solution 
or  sterilized  oil. 

Local  hemostatic  and  astringent.    It  will  render  bloodless  the  field  of  opera- 
tion of  the  eye,  nose,  and  throat,  but  its  use  is  often  followed  by  hemorrhage. 
Aluminium  Acetate,  Solution  of. 

Antiseptic  dressing  for  cellulitis,  abscesses,  etc. 

1.  I^.     Aluminii  sulphatis oSj 

Acidi  acetici o4J 

Aqu£e o  10 

2.  I^.     Calcii  carbonatis o  H 

Aqufe 5  2| 

Add  1  to  2,  stirring. 


DRUGS   FOR    EXTERNAL   USE  559 

Amylum.     See  Starch. 
Argentum.     See  Silver. 
Argyrol.     See  Silver. 
Aristol.     (Thymol  Di-iodid.) 

Mild  antiseptic,  used  as  a  dusting-powder  or  in  ointments. 
Balsam  of  Peru. 

A  stimulating  dressing  for  wounds  and  ulcers. 

In  Castor  Oil,  one  part  of  the  Balsam  to  six  of  the  oil,  it  makes  a  useful 
application  for  Ijurns  and  wounds. 
Benzoin. 

Compound  Tincture  of  Benzoin. 

Used  as  a   bronchial  sedative   in   steam   inhalations,   one-half  ounce   to 
two  pints  of  water. 
BiCHLORiD  OF  Mercury.     See  under  Mercury. 
Bismuth  Subg.^llate.     (Dermatol.) 

Used  externally  as  a  drying  antiseptic  powder,  either  pure  or  in  com- 
bination.    Also  as  an  ingredient  of  ointments  of   10%  to  20%  strength. 
Boracic  Acid.     See  Acid,  Boric. 
Cacao-butter.     (Oleum  Theobromatis.) 

A  fixed  oil  expressed  from  the  seeds  of  the  Theobroma  Cacao.  Melts 
at  30°-35°  C.  (86°-95°  F.). 

Used  as  an  emollient  and  as  a  base  for  suppositories.     It  may  be  used 
for  nutrient  inunctions,  but  it  is  less  effective  than  Goose  Oil. 
Calamine.     (Zinc  Carbonate.) 

Used  as  an   ingredient  of  soothing  lotions   in   itching  affections  of  the 
skin — eczema,  urticaria,  dermatitis  venenata,  etc. 
Calomel.     See  under  Mercury. 
Cantharides. 

Vesicant.     Used  best  in  the  form  of  Collodion  of  Cantharides,  q.  v. 
C.\RRON  Oil.     (Limentum  Calcis.) 

Consists  of  equal  parts  of  Lime-water  and  Linseed  Oil. 
Used  as  a  soothing  application  for  burns  and  scalds. 
Chloroform. 

Locally  a  rubefacient  and,  when  confined,  a  vesicant  as  well.  A  useful 
ingredient  of  liniments. 

By  inhalation,  a  general  anesthetic. 
Chrysarobin. 

LTsed  in  5%  ointment  for  psoriasis  and  tinea  tonsurans. 

COCAIN. 

Alkaloid  obtained  from  several  varieties  of  Coca. 

A  local  anesthetic  when  applied  to  wounds  or  mucous  surfaces  or  when 
injected  hypodermically. 

For  local  application,  3%  to  10%  solutions. 
For  hypodermic  use,  0.2%  to  4%  solutions. 
CoD-LivER  Oil. 

May  be  used  locally  as  a  nutrient  inunction,  but  its  odor  is  objection- 
able. 
Collodion. 

Solution  of  Pyroxylin  in  Alcohol  and  Ether. 
Collodion    of    Cantharides    (60%    Cantharides).     An    excellent    blistering^ 

agent. 
Collodion  of  Ichthyol  (10%,-20%).     Used  to  cover  the  wound  after  aspir- 
ations or  lumbar  punctures,  and  in  checking  the  spread  of  erysipelas. 
Collodion  of  Iodoform  (5%).     Used  in  erysipelas. 
Collodion  of  Oil  of  Cade  (l%-5%).     Used  in  eczema. 

Collodion  of  Salicylic  Acid  (10%).     Used  in  removing  corns  and  callouses. 
Creosote. 

Used  in  inhalations  as  a  pulmonary  antiseptic. 
Dermatol.     See  Bismuth  Subgallate. 
Eucain. 

Beta-eucain.  Local  anesthetic  with  similar  action  and  uses  to  Cocain, 
but  without  its  toxicity.  Its  solutions  can  be  sterilized  without  injury 
by  boiling. 


500  DRUGS   AND    DRUG    DOSAGE 

FORMALDEHYD. 

Antiseptic  and  deodorant. 

Used  in  solutions  of  from  0.5%  to  2%  strength,  as  an  antiseptic. 

Used  in  the  form  of  the  gas  for  disinfecting,   the  gas  being  generated 
by  heat,  from  solutions,  or  from  the  solid,  Paraform. 
Glycerin. 

Used   chiefly  as   a   solvent  or  excipient.     Very  hygroscopic.     It   is   the 
base  of  the  Glycerites. 

Glycerite  of   Carbolic  Acid — 20%   Phenol   in   Glycerin.     An   external  anti- 
septic and  antipruritic. 
Glycerite  of  Starch — 10%.     A  vehicle  for  skin  preparations  and  for  pills. 
Goose  Oil. 

The  oil  tried  from  the  goose.     An  excellent  oil  for  nutrient  inunctions. 
It  is  better  than  Olive  Oil  or  Cacao-butter,  for  being   an  animal  oil  it    is 
more  readily  absorbed  by  the  skin.     It   is  semifluid,   has  a  low  melting- 
point,  and  does  not  become  hard  after  having  been  rubbed  in. 
Grindelia  Robusta. 

The  fluidextract,  in  the  strength  of  one  dram  to  a  pint  of  water,  is  used 
as  a  wet  dressing  in  dermatitis  venenata. 

GUAIACOL. 

Combined  with  equal   parts  of  Glycerin,  it  is  used  in  acute  joint  affec- 
tions, for  its  analgesic  effect. 
HamamELIS.     See  Witch-hazel. 
Hydrargyrum.     See  Mercury. 
Hydrogen  Peroxid. 

Antiseptic   and   deodorizer.     Used  in    10-volume,   3%   solution   to  clean 
wounds,  and  to  dissolve  and  destroy  pus. 

ICHTHYOL. 

Used  in  1%  solution  in  intertrigo. 

Used  in  5%  to  50%  solutions  in  skin  diseases  or  in  erysipelas. 
Used  in  5%  to  50%  ointments  in  skin  diseases  or  in  erysipelas. 
Used  suspended  in  oil  in  strength  of  5%  to  25%  as  a  nasal  spray. 
Iodin. 

Tincture  of  Iodin  (7%). 

Antiseptic  and  counter-irritant. 

Used  particularly  in  tinea  tonsurans  and  tinea  circinata. 
Iodoform.      Formyl  Tri-iodid. 
Antiseptic  and  alterative. 

Used  in  the  form  of  a  powder,  an  ointment,  or  on  gauze  in  the  strength 
of5%o  to  10%. 
Kaolin. 

Cataplasma  Kaolini. 

A  smooth  homogeneous  mass  consisting  of  Kaolin,  Boric  Acid,  Thymol, 
Methyl  Salicylate,  Oil  of  Peppermint,  and  Glycerin. 
Lanolin. 

Used  as  an  ointment  base. 
Lead  and  Opium  Wash. 
Anodyne  lotion. 

I^.     Liquoris  plumbi  subacetatis oiv 

Tincturae   opii oj 

Aquae oxvj 

Fiat  mistura. 
Sig.- — Use  externally. 
Menthol.     (Peppermint  Camphor.) 

Sedative,  analgesic,  refrigerant,  and  antipruritic. 
Used  in  ointments,  1%  to  5%. 
Used  in  oily  solutions,  1%,  to  5%,. 

Used  triturated  with  equal  parts  of  Camphor  as  an  anodyne. 
Mercury. 

Bichlorid  of  Mercury. 

Antiseptic.     Used  in  1:1000  to  1:20,000  solutions. 
Calomel. 

A  milder  antiseptic  than  the  foregoing.     Used  as  a  dusting-powder  in 
eye  affections  and  in  the  lesions  of  secondary  syphilis. 


DRUGS  FOR  EXTERNAL  USE  561 

Mercury  and  Ammonium  Chlorid.     (White  Precipitate.) 

Used  in  ointments  of  1%  to  10%  strength  as  an  antiparasitic  and  anti- 
syphiUtic.     Of  particular  value  in  impetigo  contagiosa,  ringworm,  etc. 
Yelloxv  Oxid  of  Mercury. 

Antiseptic.     Used  in  ointments  of  0.5%  to  10%  strength  in  ophthalmia. 
Of  value  also  in  ringworm  and  syphilitic  eruptions. 
Mustard. 

Counter-irritant. 

In  the  form  of  papers  (charta;)  for  local  pain  or  vomiting. 

In  the  form  of  powder: 

In  pastes  of  a  strength  of  1  part  of  mustard  to  from  2  to  6  parts  of  flour. 
In  baths — 1  tablespoonful  to  6  gallons  of  water. 
In  packs,  in  the  same  proportion. 
Oil  of  Cade.     (Oil  of  Juniper  Tar.) 

Used  as  an  antiparasitic  in  skin  diseases. 
In  powders,  1%  to  5%  in  a  base  of  Stearate  of  Zinc. 
In  ointments,  1%  to  5%. 
In  Collodion,  1%  to  5%. 
Oil  of  Turpentine.     (Spirits  of  Turpentine.) 
Rubefacient  and  counter-irritant. 
Used  as  an  ingredient  of  liniments. 

Used  in  the  form  of  turpentine  stupes  for  the  relief  of  abdominal  distention. 
Flannel  cloths  are  wrung  out  in  hot  water  to  each  pint  of  which  gtt.  10-20  of 
Oil  of  Turpentine  have  been  added,  and  are  then  applied  to  the  abdomen. 
OuvE  Oil. 

Used  externally  as  a  nutrient  inunction. 
Petrolatum  (Petroleum  Jelly  or  "Vaselin"). 

Used  as  a  base  for  ointments. 
Phenol.     (Pharmacopeial  name  of  Carbolic  Acid.) 
Local  anesthetic  and  antiseptic. 

Used  as  an  antiseptic  in  solutions  of  the  strength  of  5%  or  less. 
Used  as  a  caustic  and  local  anesthetic  in  strength  of  95%. 
Children  are  very  susceptible  to  Phenol  poisoning. 
Pix  Liquida.     See  Tar. 
Potassium  Permanganate. 

Antiseptic  and  disinfectant. 

Used  in  solutions  in  the  strength   of  1 :  4000  to  1 :  2000  on  mucous  sur- 
faces, and  in  the  strength  of  1 :  1000  on  ulcers  and  superficial  wounds. 
Resorcin. 

Antiseptic  in  skin  diseases,  particularly  in  seborrheic  eczema. 
Lotions,  1%  to  5%. 
Ointments,  1%  to  5%. 
Silver. 

Silver  Nitrate.     Antiseptic   and   astringent.     Used   in   solutions   of   1%   to 

50%  strength.     As  a  caustic,  it  is  used  in  the  solid  form. 
Argyrol.     (Silver  Vitellin — Proprietary.) 

A   mild   antiseptic,    not   approaching   the   Nitrate  in  efhcacy.     Used   in 
solutions  of  5%  to  50%  strength  or  in  ointments  of  5%  to  50%  strength. 
Sodium  Bicarbonate. 

Used  in  saturated  solution  as  an  antipruritic  and  as  an  analgesic  in  skin 
diseases  and  burns. 
Starch. 

Used  as  the  base  of  drying-powders. 
Sulphur. 

In  5%  to  55%  ointments  as  a  parasiticide,  particularly  in  scabies. 
Tar.     (Pix  Liquida.) 

Antiseptic.     Used   in   skin  diseases  as  the  officinal  ointment  (50%)    or 
in  ointments  with  other  ingredients. 
Zinc  Oxid. 

Used  as  a  20%  ointment  in  Benzoinated  Lard,   in  skin    diseases,   such 
as  eczema,  needing  a  mild  astringent. 

Used  in  dusting-powders  in  the  strength  of  5%  to  10%. 
Official  Zinc  Ointment  makes  a  good  base  for  stronger  antiseptics,  such 
as  Tar  and  Oil  of  Cade. 
.^,6 


INDEX 


Abdominal  distention  as  sign  of  peri- 
tonitis, 469 
in  chronic  ileocolitis,  204 
in  inactive  enteric  infection,  197 
massage  in  constipation,  175 
Abscess,  ischiorectal,  218 
of  breast,  53 

peritonsillar,  incision  of,  240 
situations  of,  240 
treatment  of,  241 
retropharyngeal,  244 
breathing  in,  244 
examination  of  throat  in,  244 
incision  of,  244 
position  of  head  in,  244 
treatment  of  dysphagia  in,  244 
Absorption  of  saline  solution  in  colon 

irrigation,  209 
Acarus  scabiei,  412 
Acetone,    absence    of,    in    glycosuria, 

350 
Aconite,  tincture  of,  in  fever,  476 
in  nephritis,  345 
in  pericarditis,  289 
in  pleurisy,  279 
Adams'  position,  522 
Adapted  milk,  94 

Adenitis,  acute,  treatment  of,  424,  425 
cervical,  confused  with  mumps,  334 
in  diphtheria,  302 
in  scarlet  fever,  319 
persistent,  425 
retropharyngeal,  115,  429 
suppurative,  242 
tubercular,  treatment  of,  430 
Adenoids,  426 

as  cause  of  cough,  254,  324 
of  incontinence  of  urine,  338 
of  laryngeal  croup,  246 
of  nasal  catarrh,  232 
of  nasal  hemorrhage,  234 
of  otitis,  418 

of  persistent  deafness?  422 
associated  with  asthma,  263 
cough  of,  426 
crushing  of,  427 
deterrent  to  growth,  143 
in  chronic  otitis  media,  422 
in  epileptics,  372 
in  laryngismus  stridulus,  251 
in  night-terrors,  363 
mouth-breathing  due  to,  426 


Adenoids,  occurrence  of,  426 
operation  for,  427 
removal  of,  for   chronic    bronchitis, 

261 
return  of,  after  operation,  429 
treatment  of,  427 
without  mouth  breathing,  232 
Adherent    pleura  as    cause    of   persis- 
tent cough,  255,  256 
Adhesive    plaster    strapping    in    pleu- 
risy, 278 
in  umbilical  hernia,  396 
in  ventral  hernia,  397 
Adirondacks,  good  for  older  children, 

501 
Adrenalin  in  hemorrhagic  diseases  of 
the  newly  born,  54  ^ 

in  nasal  hemorrhage,  224 
Afternoon  nap,  27,  28 
Air-cushion  in  decubitus,  413 
Airing  nursery  and  sleeping-room,  58 
Air-space  necessary  in  nursery,  24 
Albolene  inunctions  in  measles,  331 
in  rhinitis,  230 
spray  in  scarlet  fever,  318 
Albuminuria,  342 

clothing  in  a  case  of,  343 
cyclic,  342 

diet  in  a  case  of,  343 
dietetic,  342 

examination  of  urine  in,  343 
febrile,  342 
laxatives  in,  343 
management  of  cases,  343 
paroxysmal,  342 
transient,  342 
Albumin-water,  formula  for  preparing, 

123 
Alcohol,  abuse  of,  299 
administration  of,  503 

by  rectum,  hypodermatically,  etc., 
498 
and  mother's  milk,  70 
and  water,  bath  of,  30 
for  sponging,  480 
in  noma,  225 
as  cause  of  cerebral  palsy,  383 
of  delicate  children,  149 
of  multiple  neuritis,  381 
as  drug,  not  a  beverage,  497 
as  food  during  illness,  133 
as  galactagogue,  108 


563 


564 


INDEX 


Alcohol  for  nipples,  224 

habit    easily    acquired    in     chronic 

ileocolitis,  205 
in  bronchopneumonia,  270,  271 
in  collapse,  498 
in  diphtheria,  310 
in  gastro-intestinal  infection,  191 
in  lobar  pneumonia,  277 
in  neurotic  children,  363 
in  prevention  of  decubitus,  413 
in  purpura,  450 
in  scarlet  fever,  318 
in  severe  toxemia,  497 
in  typhoid  fever,  461 
in  vomiting,  192 
irritant  to  the  kidneys,  497 
narcosis,  gavage  in,  137 
physiologic  action,  497 
to  increase  fat  in  breast-milk,  167 
tolerance  for,  497 
used  harmfuUy,  19 
when  to  give,  497 
Alderney  cream,  107 
Alkalies  in    the    adaptation    of    cow's 

milk  proteid,  95 
Aloes,  tincture   of,    in   finger  sucking, 

432 
Alternating  use   of   drugs   in   cystitis, 

352 
Alum  in  pertussis,  325 
Ammonium    salts,    administration   of, 
503 
for  children,  269 
in  bronchitis,  260 
in  lobar  pneumonia,  277 
interfering  with  digestion,  19 
unpalatable,  503 
Anemias  of  infancy,  438 
bathing  in,  438 
country  hving  in,  438 
fresh  air  in,  438 
in  cardiac  disease,  298 
intestinal  toxemia  a  cause  of,  438 
lack  of  appetite  a  cause  of,  125 
Anesthetics,  gas-ether  sequence,  495 
in  children,  494 
use  of,  in  thoracotomy,  282 
Angina,  recurrent,  233 

associated    with    cardiac    disease, 
296 
Angioneurotic  edema,  387 
Antacids  in  milk  adaptation,  95 
Anterior  poliomyelitis,  378 

exercises  for,  541 
Antipyretic  drugs  for  fever,  476 
in  lobar  pneumonia,  275 
in  tvphoid  fever,  459 
Antipyrin,  264 

as  an  antipyretic,  477 
as  cause  of  purpura,  449 

of  urticaria,  407 
in  catarrhal  laryngitis,  250 
in  laryngismus,  252 


Antipyrin  in  nasal  hemorrhage,  234 

with  sodium  bromid  in  pertussis,  327 
Antirheumatic    treatment    in    peliosis 
rheumatica,  468 
in  tonsillitis,  239 
Antispasmodic  treatment  in  catarrhal 

croup,  248,  249 
Antitetanic  serum,  54 
Antitoxin,  diphtheritic,  302 
administration  of,  302,  304 
amount  necessary,  303,  304 
as  cause  of  urticaria,  409 
dosage  for  immunization,  308 
for  laryngeal  diphtheria,  303 
effect  on  blood,  307 
in  cervical  adenitis,  425 
in   doubtful   cases   of   diphtheria, 

237 
in  laryngeal  diphtheria,  314 
in  nasal  catarrh,  233 
in  rhinitis,  chronic,  233 
in  suspicious  throats,  238 
late  in  diphtheria,  306 
repetition  of,  304 
site  of  injection,  308 
when  and  how  to  use,  303 
rash,  percentage  of  occurrence,  307 
Anus,  inflammation  of,  213 
prolapse  of,  216 
!    Aortic  disease,  conduct  of  life  in,  297 
Aphtha-,  Bednar's,  225 
Appendicitis,  210,  211 
Appetite,  habitual  loss  of,  125 
poor,  due  to  fissures  of  lips,  226 
to  too  frequent  feeding,  125 
Apple,  baked,  when  allowed,  130 
raw,  when  allowed,  131 
for  constipation,  163 
sauce,  when  allowed,  130 
scraped,  in  constipation,  172 
Aristol    collodion    for    lumbar    punc- 
ture holes,  374 
to  cover  needle  holes,  356 
Arizona  in  tuberculosis,  501 
Arnold  steam  atomizer,  328 

sterilizer.  1 1 1 
Arsenic  as  cause  of  urticaria,  407 
in  cardiac  disease,  298 
in  chlorosis,  441 
in  chorea,  369 
in  diabetes,  351 
in  habit  spasm,  371 
in  hysteria,  362 
schedule  in  chorea,  369 
signs  of  overdose,  370 
Arsenical  multiple  neuritis,  381 
Arthritis  in  scarlatina,  327 
Artificial  feeding,  80-98 

respiration    in    asphyxia    of    newly 
born,  48 
Dew's  method,  48 
Laborde's  method,  48 
Schultze's  method,  48 


INDEX 


565 


Ascaris  lumbricoides,  214 
Asparagus,  when  allowed,  130 
Asphyxia  in  the  newly  born,  48 
Asphyxiation  from  nitrous  oxid,  495 
Aspidium,  oleoresin  of,  in  tape-worm, 

216 
Aspiration      of      carbolic      acid      into 
larynx,  253 
of  hydrocele,  356 
of  pericardium,  290 
Aspirin  in  chorea,  368 
in  cyclic  vomiting,  473 
in  endocarditis,  292 
in  habit  spasm,  371 
in  pericarditis,  290 
in  recurrent  bronchitis,  262 
in  rheumatism,  467 
Asthma    associated   with   cardiac   dis- 
ease, 296 
bicarbonate  of  soda  in,  266 
bowel  function  in,  266 
drugs  in,  264-266 

due  to  irritation  by  pollen  of  plants, 
263 
to  Hthemic  diathesis,  267 
to  rheumatism,  465 
in  recurrent  bronchitis,  263 
inhalations  in,  265 
red  meat  in,  266 
rheumatic  inheritance  in,  263 
salicylate  of  soda  in,  266 
Astringents  in  diarrhea,  194 
Ataxia,  congenital,  exercises  fo^,  526 
Atelectasis,  51 
death  from,  51 

due  to  compression  of  fluid,  51 
Athrepsia.     See  Marasmus. 
Atlantic  City  after  grippe,  454 

for  convalescents,  500 
Atropin  in  incontinence   of  urine,   340 
in  night  sweats,  287 
with  morphin,  192 
Axillary  temperature,  475 


Babcock  milk  test,  107 
Baby,  basket,  19 
clothes,  20 

condition  of,  best  guide  to  wet-nurse, 
74 
Babies'  Hospital  Dispensary,  percent- 
age of  normal  development  in 
children,  56 
rules  for  feeding  children,  92 
Bacillus,  Klebs-Loffler,  causing  chronic 
nasal  discharge,  232 
diphtheria,  302,  303 
Backward  children,  often  deaf,  422 

with  adenoids,  etc.,  422 
Bacterial  examination  for  diphtheria, 
303 
of   vaginal   discharge   before    dis- 
charge of  patient,  358 


Baked  flours,  119 
Balanitis,  treatment  of,  354 
Balsam  of  Peru  for  sluggish   granula- 
tions, 218 
Barley  gruel,  when  allowed,  129 
jelly,  formula  for  preparing,  123 
water   after   gastro-intestinal   infec- 
tion, 192 
before  nursing,  70 
in  acute  ileocolitis,  200 
in  diarrhea,  161 
formula?  for  preparing,  123 
Basket  for  baby's  toilet,  19 

for  early  exercise,  25 
Bassorin  paste  in  eczema,  402 
Bathing,  58 
after  meals,  30 
of  delicate  children,  148 
in  ihness,  58 
necessity  of  daily,  146 
of  premature  infant,  45 
Bath-room,  temperature  of,  29,  483 
Baths,  alternate  hot  and  cold,  252 
and  meals,  30 
brine,  31 
cool,  29 

during  illness,  483 
hot,  31 

in  anemia,   439 

in  chronic  diffuse  nephritis,  348 
in  furunculosis,  412 
in  lobar  pneumonia,  275 
in  typhoid  fever,  456 
mustard,  30 
overcoming  fear  of,  29 
reaction  after,  30 
soda,  31 
starch,  31 

temperature,  for  fever,  30 
for  one  year  old,  29 
for  very  young,  29 
time  for  daily,  30 
tub,  29,  30 
varieties,  basin,  30 
bran,  31 
Beans,  dried,  in    dietary    of    delicate 

children,  145 
Bed -clothing,    care  of,  in    quarantine, 

304 
Bednar's  aphthae,  225 
Bed-sores,  413 
Bed-time,  43 

Bed-wetting.     See  Incontinence  of  urine. 
Beef  broth,     formula     for    preparing, 
123 
foods,  119 
juice,  formula  for  prepanng,  123 

in  marasmus,  156 

scraped,  formula  for  preparing,  123 

Beer  after  sixth  year,  132 

Belladonna,  extract  of,  66 

in  constipation,  164 

in  epilepsy,  373 


566 


INDEX 


Belladonna,    extract    of,   in    pertussis, 
326 
in  rhinitis,  229 
Bicarbonate   of  soda  in  asthma,  266 
in  bath,  31 

in  bronchitis,  recurrent,  261,  262 
in  cardiac  disease,  296 
in  chorea,  368 
in  cyclic  vomiting,  473 
in  eczema,  402,  403 
in  intertrigo,  404 
in  persistent  vomiting,  178 
in  quinsy,  241 
in  rheumatism,  464 
Bichlorid  bath  after  quarantine,  302 
of  mercury,  administration  of,  503 
an  irritant  drug,  503 
as  an  ear  irrigation,  421 
as  a  wet  dressing,  49 
for  thread-worms,  216 
in  anemia,  440 
in  balanitis,  354 
in  congenital  syphilis,  288-290 
in  mastitis  of  young  girls,  52 
in  noma,  225 
in  paraphimosis,  354 
in  otitis  media,  chronic,  422 
in  ringworm  of  the  scalp,  414-416 
in   tardy  malnutrition   of   syphil- 
itic origin,  393 
in  tetanus,  54 
in  typhoid  excreta,  457 
Biedert,  quoted,  322 
Binder  for  breasts,  78 
Bird's  eye  diapering,  20 
Bismuth  mixture,  194 

subnitrate,  impure,  poisoning  from, 
194 
in  diarrhea,  194 

of  scarlet  fever,  459 
in  dilatation  of  the  stomach,  184 
in  ileocolitis,  201 

with  Dover's  powder  in  fecal  in- 
continence, 219 
Biting  finger-nails,  432 
Bladder,  irrigation  of,  in  cystitis,  352 
non-development  of,   due   to   incon- 
tinence, 338 
stone  in,  351 

weakness  of  sphincter  of,  in  enure- 
sis, 338 
Bleeding   from   breast    causing   hema- 

temesis,  182 
Blindness,  transitory,  in  pertussis,  323 
Blisters  to  spine  in  poliomyelitis,  379 
Blood-streaked  stool  due  to  fissure  of 

anus,  213 
Boarding-schools  for  the  cure  of  hys- 
teria, 361 
Body-heat,  maintenance  of,  in  prema- 
ture infants,  45 
Boiled  milk  a  cause  of  constipation, 
171 


Boils,  411 

Bone,  dead,  a  cause  of  chronic  ear  dis- 
charge, 423 
tuberculous  disease  of,  471 
Borax  water  for  nipples,  23 

for  rectal  irrigation  in  worms,  216 
Boric  acid  in  dusting-powder,  52 
insufflations  in  pertussis,  324 
ointment,     10    per    cent,    in    cold 
cream,  333 
in  contagious  impetigo,  408 
in  fissure  of  lips,  220 
in  furunculosis,  412 
in  ivy  poisoning,  411 
in  mammary  abscess  of  infants, 

53 
in  vaccination  wounds,  486 
saturated  solution  of,  78 

in  Bednar's  aphthae,  226 

in  care  of  nipples,  73 

in  cleansing  teeth,  35 

in  gonorrheal  vaginitis,  358 

in  measles,  331 

in  noma,  225 

in    retropharyngeal    adenitis, 

430 
in  tonsillitis,  238 
mouth-wash  of,  49 
wet  dressing  of,  49 

for     vaccination     ulcers, 
485 
Bottle-fed,  constipation  in,  169 
Bottle-feeding  in  breast-fed,  70 
Bowel  function,  166 

defective,  a  cause  of  colic,  165 
in  asthmatics,  266 
in  epilepsy,  372 
in  lobar  pneumonia,  274 
in  nephritis,  344 
in  scarlet  fever,  316 
in  tubercular  peritonitis,  469 
of  intestinal  intoxication,  166 
treatment  of,  166 
Bow-legs,  rachitic,  444 
Boys,  hysteria  in,  360 
Braces  after  poliomyelitis,  379 
for  bow-legs,  444 
for  masturbation,  436 
to  prevent  contractures,  384 
Brachial  plexus,  injury  to,  during  labor, 

386 
Brain  lesion  as  cause  of  early  convul- 
sions, 363 
Bran  bath  in  eczema,  403 

in  prickly  heat,  416 
Brandy,   50,    191,  277,    497.     See  also 

Alcohol. 
Breast,  abscess  of,  in  newly  born,  57 
in  infants,  53 
bandaging,  during  weaning,  71 
binder  for,  78,  79 
caking  of,  78 
care  of,  during  weaning,  71 


INDEX 


567 


Breast  feeding  in  marantic  infants,  152 
massage  of,  78 
milk  by  gavage,  137 

in  chronic  ileocolitis,  205 
regulation  of  percentages  in,  69,  70 
time  of  appearance  of,  72 
pump,  78 
Breath  of  diphtheritic  patient,  302 
Breathing,  exercises  for,  513-516 
Breck  feeder  in  premature  infants,  47 
Brine  baths,  31,  138 

for  neurotic  children,  362 
in  rickets,  443 
in  tardy  malnutrition,  159 
in  tetany,  367 
with  goose  oil  rub,  443 
Bromid  of  soda,  250,  264 

in  anterior  poHomyelitis,  378 
in  convulsions,  364 
in  cough  after  intubation,  313 
in  endocarditis,  291 
in  epilepsy,  372 
in  gyro-spasm,  366 
in  hiccough,  387 
in  hysteria,  363 
in  laryngismus,  252 
in  measles-cough,  332 
in  meningitis,  375 
in  nephritis,  347 
in  neuritis,  382 
in  night-terrors,  365 
in  persistent  hematemesis,  185 
in  pertussis,  326 
in  polyuria,  350 
in  tetanus  neonatorum,  54 
in  tetany,  367 
Bromoform  in  pertussis,  325 
Bronchiectasis,  interstitial,  287 
Bronchitis  as  complication  of  influenza,   j 
453 
associated  with   bronchopneumonia, 
257 
with  measles,  257 
with  whooping-cough,  257 
duration  of,  258 
fever  range  in,  257 
mustard  paste  in,  493 
physical  signs  in,  257 
predisposing   to  bronchopneumonia, 

267 
recurrent,  due  to  rheumatic  habit,  463 
respirations  in,  258 
signs    of    developing    bronchopneu- 
monia in,  257 
svmptoms  of,  257 
treatment  of,  258-261 
varieties,  257 
Bronchopneumonia.     See    Pneumonia, 

broncho-. 
Broths  after  diarrhea,  194 

formulae  for  preparing  beef,  chicken, 

and  mutton  broth,  123 
in  ileocolitis,  201 


Broths  in  illness,  133 

in  nephritis,  344 

nutriment  of  animal,  310 

when  allowed,  129 
Buckwheat  as  cause  of  urticaria,  407 
Bullae  of  skin  in  pemphigus,  409 
Bunge,  quoted,  439 
Butter  in  milk  idiosyncrasy,  1 1  1 

to  replace  the  fat  of  milk,  146 

wlien  allowed,  130 
Button  for  umbilical  hernia,  396 


Cacao-butter  rub,  139 

CalTein  in  bronchopneumonia,  270 

in  fever,  477 

in  influenza,  452 
Caking  of  breasts,  78 
California,  for  nephritis  cases,  500 
Calomel  and  rhubarb  in   pharyngitis, 
236 

contraindicated,  in  the  cure  of  con- 
stipation, 173 

fumigations  in  catarrhal  croup,  250 

in  chronic  eczema,  404 

in  gastric  indigestion,  178 

in  ileocolitis,  201 
chronic,  206 

in  influenza,  452 

in  lobar  pneumonia,  274 

in  pleurisy,  279 

in  tonsillitis,  238 

initial  dose,  in  acute  gastro-intestinal 
infection,  192 

vs.  castor  oil  in  acute  gastro-intesti- 
nal infection,  192 
Camphor  as  a  counterirritant,  493 

as  a  heart  stimulant,  277 

in  hemorrhoids,  218 

in  rhinitis,  231 

water  in  earache,  418 
Camphorated  oil  in  mumps,  334 
Cancrum  oris,  treatment  of,  224 
Candy  in  chorea,  368 
Canine  teeth,  time  of  appearance  of,  35 
Cantharides,  tincture  of,  342 
Capsicum  as  a  counterirritant,  493 
Capsules  for  unpalatable  drugs,  504 
Carbohydrates,   action  of,   on  flora  of 
intestine,  120 

essential  ingredients  of,  59 

function  of,  as  foods,  60 

in  diarrhea,  161 

where  found,  59 
Carbolic   acid    in    post-antitoxin   urti- 
caria, 307 
in  ringworm  of  the  scalp,  414 
solution  of,  for  bed-clothes,  301 
Cardiac  disease,  prognosis  in,  297 
Care  of  bottles  to  prevent  sprue,  224 

of  breasts  to  prevent  sprue,  223 

of  milk  on  farm,  190 

of  mouth  to  prevent  sprue,  224 


568 


INDEX 


Cascara  sagrada,  66,  206 

in  cardiac  disease,  298 

in  colic,  166 

in  constipation,  164,  173,  170 

in  hysteria,  362 

in  scarlet  fever,  316 
Casein,  60,  99 

causing  constipation,  169.    See    also 

Milk. 
cow's,  of  case  records,  39 
Cases,  illustrative,  of  abundant  but  too 
weak  milk,  69 

of  adenoids  as  a  cause  of   persis- 
tent cough,  256 

of  adherent   pleura  as  a  cause  of 
persistent  cough,  256 

of  angioneurotic  edema,  357 

of  antipyretics  in  typhoid  fever, 
459 

of  bed  wetting,  339 

of  cerebral  hemorrhage  and  palsy, 
384 

of  chronic  ileocolitis,  205 

of  colon  flushing,  496 

of  cow's  milk  idiosyncrasy,  110 

of  day  terrors  of  intestinal  origin, 
163 

of  death  from  pericranial  hemor- 
rhage in  the  newly  born,  54 

of  double  empyema,  284 

of  dysarthria  from  intestinal  toxe- 
mia, 163 

of  eczema,  402 

of  empyema    after    bronchopneu- 
monia, 283 

of  empyema  necessitatis,  284 

of  epilepsy,  373 

of  erythema  nodosum,  410 

of  excessive  feeding,  157 

of  fatal  grippe,  453 

laryngismus  stridulus,  251 

of  fatigue  fever,  478 

of  fecal  impaction,  210 

of  fissure  of  the  anus,  214 

of  gavage  in  malnutrition,  137 
in  persistent  vomiting,  135 

of  hematemesis     from     blood     in 
breast  milk,  183 

of  hemophilia,  450 

of  history  of  marasmus,  152 

of   hyperpyrexia    from    ulcerative 
stomatitis,  221 

of  hysteria  in  the  third  generation, 
360 

of  ileocohtis,  200 

of  inactive  type  of  intestinal  infec- 
tion, 198 

of  incubation  period  of  pertussis, 
322 

of  intestinal    obstruction    due    to 
Meckel's  diverticulum,  210 

of  intubation,  313 

of  intussusception,  212 


Cases,  illustrative,  of  malignant  endo- 
carditis, 293 
of  masturbation,  435 
of  mildness  of  pertussis,  323 
of  milk-giving  in  typhoid,  458 
of  mucous  colitis,  206 

phenomena  of  intestinal  indiges- 
tion, 162 
of  myocarditis,  295 
of  nervous  causes  of  vomiting,  176 
of   night-terrors   from  overeating, 

365 
of  oil  treatment  for  constipation, 

175 
of  otitis  media,  419 
of  overfeeding  in  nurslings,  69 
of  persistent  glycosuria,  349 
of  post-diphtheritic  paralysis,  380 
of    primary    tuberculous    pleurisy 

with  effusion,  280 
of  quarantine,  301 
of  rectal  feeding,  141 
of  recurrent  bronchitis,  465 

without  asthma,  261 
of    retropharyngeal    abscess,   243, 

244 
of  rheumatism  in  acute  endocardi- 
tis, 292 

in  asthma,  264 
of  rickets,  wet-nursing,  442 
of  round-worm  infection,  215 
of  septic  infection  of  the  navel,  50 
of  severe  intestinal  infection,  198 
of  tardy  malnutrition,  159 
of   thyroid   extract   in   cretinism, 

446' 
of  traumatic  laryngitis  from   the 

inhalation  of  carbolic  acid,  253 
of  ulceration  of  the  stomach,  184 
of  unexplained  temperature,  480 
of  use  of  antitoxin  before  diagno- 
sis, 303  _ 
in  intubation  cases,  305 

of  lavage  in  vomiting,  182 
Castor  oil,  197 

administration  of,  503 

in  bronchitis,  260 

in  constipation,  174 

in  convulsions,  364 

in  icterus  neonatorum,  50 

in  ileocohtis,  201,206 

in  influenza,  452 

in  intestinal  indigestion,  161 

infection,  197 
in  laryngitis,  248 
in  round-worms,  214,  215 
in  summer  complaint,  189 
in  tape-worm,  216 
in  tetany,  366 
in  urticaria,  408 
in  worms,  214-216 
initial  dose  in  acute  gastro-intes- 

tinal  infection,  192 


INDEX 


569 


Catarrh,  nasal,  due  to  adenoids,  232 
to  hay-fever,  232 
to  liyi)ertn)phied  turbinates,  232 
to  Klcbs-Lofller  bacillus,  232 
to  malnutrition,  232 
treatment  of,  233 
Catarrhal    pneumonia.     See    Pneumo- 
nia, broncho-. 
Catheterization  of  larynx  in  asphyxia 
of  the  newly  born,  49 
of  urethra  in  retention  of  urine,  337 
Catheters,    soft-rubber,    as     stomach- 
tubes,  136 
CauHflower,  when  allowed,  131 
Cauterization  of  hypertrophied  tonsils, 
239 
of  nasal  septum  in  nasal  hemorrhage, 
234 
Cavities  in  first  teeth,  35 
Cephalhematoma,  50 
suppuration  in,  50 
treatment  of,  50 
Cereal  gruels,  119 

beginning  feeding  of,  120 
in  acute  illness,  120,  133 

intestinal  infection,  197 
in  condensed  milk  feeding,  114 
in  cow's  milk,  idiosyncrasies,  110 
in  difficult  cases,  109 
in  feeding  dispensary  patients,  93 
in  milk  adaptation,  97 
not  good  for  an  exclusive  diet,  120 
percentages  of,  124 
to  replace  milk,  120 
variety  in  kind  of  value,  192 
Cereals,  high  proteid,  145 
in  nephritis,  344 
ready  to  serve,  145 
when  allowed,  128 
with  butter  and  sugar,  1 74 
Cerebellar  ataxia,  hereditary,  527 
Cerebral  palsy  associated  with  idiocy, 
385 
varieties  of,  prenatal,   birth,   post- 
natal, 383 
Cereo   for    dextrinizing    cereal    gruels, 
124 
in  typhoid  fever,  457 
Cerium  oxalate  in  gastric  indigestion, 

178 
Certified  milk,  188 

requirements    of    the    New    York 
Covmty    Medical    Society    Milk 
Commission  for  the  production 
of,  104 
Cervical  adenitis  due  to  adenoids,  424 
to  decayed  teeth,  424 
to  large  tonsils,  424 
in  typhoid  fever,  457 
caries,  tubercular,  245 
Chair  suitable  for  children,  510 
Changes  in  temperature,  sudden,  dan- 
gerous in  nephritis,  500 


Chapin  dipper,  84,  171 

Cheese   cloth    for   diapers    in    typhoid 

fever,  457 
Cherries,  when  allowed,  131 
Chicken  broth,  formula  f(jr  jircparing, 

123 
Chicken-pox,  332.     See   also   Varicella. 
Child  nagging,  58 

Chill    in   onset    of    pneumonia,    lobar, 
272 
in  pyelitis,  352 
Chilling  skin  a  cause  of  suppression  of 

urine,  337 
Chloral  hydrate,  185 
in  convulsions  364 
in  laryngismus,  252 
in  meningitis,  375 
in  tetanus  neonatorum,  54 
in  uremic  convulsions,  346 
Chlorate  of  potash,  effect  on  kidneys,. 
223 
in  stomatitis,  222 
in  tonsillitis,  239 
Chlorid  of  iron,  administration,  504 
Chloroform  as  an  anesthetic  in  children, 
495 
as  a  counterirritant,  493 
contraindications  for,  495 
danger-signals  in  use  of,  495 
in  asthma  of  older  children,  265 
in  convulsions,  364 
sudden  death  from,  449 
Chlorosis,  438 

country  Hving  in,  440 
treatment  of,  440 
Cholelithiasis  causing  jaundice,  437 
Cholera  infantum,  191 
Chorea,  367-370 

anti-rheumatic  diet  in,  368 
arsenic  in,  369 
aspirin  in,  369 

associated  with  cardiac  disease,  296 
bicarbonate  in,  368 
candy  in,  368 
Fowler's  solution  in,  369 
intermittent  medication  in   369 
meat  eating  in,  368 
play  in,  368 
rest  treatment  in,  367 
rheumatism  in,  367,  368 
salicylates  in,  368 
school  in,  368 
sugar  in,  368 
Choreiform   movements   due   to   intes- 
tinal toxemia,  162 
Chrysarobin  in  ringworm  of  the  scalp,. 

414 
Circumcision,  354 
after  balanitis,  354 
death  of  a  bleeder  after,  451 
for  masturbation,  434 
for  paraphimosis,  354 
for  phimosis,  353 


570 


Circumcision  for  the  relief  of    painful 

micturition,  336 
Citrate  of  iron.     See  Iron. 
of  magnesia.     See  Magnesia. 
of  potash.     See  Potassium. 
Clean  milk,  cost  of  producing,  103 
Cleft-palate,  398 
feeding  in,  399 
operation  for,  398 
Climate,  change  of,  to  cure  grippe,  454 
in  asthma,  263,  500 
in  bronchiectasis,  287 
in  care  of  delicate  children,  143 
in  cure  of  poor  appetite,  126 
in  intestinal  diseases,  186,  203 
in  nephritis,  349 
in  pulmonary  diseases,  501 
in  tuberculosis,  285,  501 
therapeutic  value  of,  500 
Clitoris,  adhesions  of,  a  cause  of  incon- 
tinence of  urine,  338 
of  masturbation,  434 
deterrent  to  growth,  143 
Clothing,  509 

average  weight  of,  32 

for  dehcate  children,  147 

for  summer  months,  487 

for  use  in  gymnastic    therapeutics, 

506 
in  anemia,  439 
in  bronchopneumonia,  267 
in  lobar  pneumonia,  274 
too  heavy  in  sickness,  19 
Coal-tar  products  in  typhoid  fever,  459 
Coast  towns  in  summer,  500 
Cocain  anesthesia  for  thoracotomy,  282 
in  earache,  418 
in  fissure  of  anus,  214 
in  pertussis,  325 
Cocoa  in  malted  milk,  172 
Coddled  egg  in  ileocolitis,  205 
Codein  in  asthma,  265 
in  cough  of  measles,  222 

of  pleurisy,  279 
in  diphtheritic  paralysis,  380 
in  endocarditis,  291 
in  meningitis,  375 
in  multiple  neuritis,  382 
in  pericarditis,  371 
in  pertussis,  327 
Cod-liver  oil,  371 

in  bronchiectasis,  285 

in  cardiac  disease,  298 

in  condensed  milk  feeding,  164 

in  constipation,  170 

in  marasmus,  156 

in  milk  idiosyncrasy,  110 

in  neuritis,  382 

in  neurotic  children,  363 

in  nurslings,  168 

in  persistent  adenitis,  425 

in  tubercular  adenitis,  430 

in  vulvovaginitis,  357 


Coffee  after  sixth  year,  132 
in  typhoid,  457 

insufflations  of,  in  pertussis,  324 
Coit,  H.  L.,  organizer  of  the  first  milk 

commission,  103 
Cold    air,  contraindicated   in   asthma, 

265 
baths,  uses  of,  499 
coil,  use  of,  499 
compress  in  catarrhal  croup,  249 

in  tonsillitis,  239 

use  of,  499 
cream  inunction  in  measles,  331 
douche  in  neurotic  children,  362 

uses  of,  500 
dry  air  in  summer,  500 
feet  and  colic,  165 

foods,  better  retained  than  hot,  178 
in  delicate  children,  147 
pack,  481 

in  bronchopneumonia,  270,  271 

in  diphtheria,  310 

in  endocarditis,  malignant,  293 

in  erysipelas,  463 

in  fever,  476 

in  gastro-intestinal  infection  of  the 
choleraic  type,  191 

in  influenza,  452 

in  lobar  pneumonia,  275 
sponging  in  fever,  480 

in  grippe,  452 

in  hot  weather,  481 

in  pneumonia   271 

in  typhoid  fever,  456,  460 

uses  of,  499 
therapeutic  uses  of,  499 
water   enema   after   colon    flushing, 

198 
Cold,  chronic,  due  to  adenoids,  427 

in  head,  228,  229 
Colic  causing  hernia,  395 
due  to  decomposition,  165 

to  defective  bowel  action,  165 

to  milk  proteid,  165 

to  mother's  constipation,  165 

to  round-worms,  214 

to  too  much  fat,  89 

to  too  much  proteid,  89 

to  too  strong  food   89 
in  bottle-fed,  165 
in  breast-fed,  165 
in  difficult  feeding  cases,  108 
nervous  causes  of,  165 
stupes  in,  494 
treatment  of,  253 
Coliopyelitis,  352 
Colitis,  as  cause  of   fecal  incontinence, 

218 
chronic,  years  to  get  results  in,  18 
Collecting  urine,  device  for,  336 
Colon  bacillus  in  cystitis,  351 

in  urine  of  pyelitis,  352 
flushing,  496 


INDEX 


57] 


Colon  flushing,  apparatus  for,  208 
in  cyclic  .vomiting,  472 
in  gastro-inlestinal  infection,  191, 

192,  193 
in  ileocolitis,  205,  207 
in  intestinal  infection,  198 
in  mucous  colitis,  206 
in  nephritis,  345 

in  persistent  vomiting  cases,  178 
in  pneumonia,  lobar,  278 
in  suppression  of  urine,  337 
indications  for,  208 
irrigation  in  acute  intestinal  infec- 
tion, 199 
in  fever,  208 
medication    in    laryngismus    stridu- 
lus, 253 
Colostrum,  72 
Coma,  gavage  of  peptonized   milk  in, 

115 
Comfort  baths  for  hot  weather,  30 
Condensed  milk  after  diarrhea,  196 
analysis  of,  114 
as  cause  of  malnutrition,  151 

of  rickets,  442 
as  sick  food,  114 
for  summer,  155 
for  travehng,  116 

in  convalescence  of  ileocolitis,  204 
in  difficult  feeding  cases,  108 
in  out-patient  work,  93 
in  premature  infants,  47 
Conduct  of  life  in  valvular  disease  of 

the  heart,  296,  299 

Congenital   defects    causing    intestinal 

obstruction,  209 

heart  disease,  299 

pyloric  stenosis,  185 

Congestion,  internal,  494 

counterirritation  for,  494 
Constipation  after  diarrhea,  197 
after  ileocolitis,  204 
cascara  in,  168 

due  to  fissure  of  the  rectum,  170 
to  inflammation  of  anus,  213 
to  sterihzing  milk,  1 1 1 
to  too  high  fat,  171 
to  too  low  fat,  67 
gymnastic  exercises  for,  539 
in  bottle-fed,  169 
in  chronic  ileocolitis,  205 
in  difficult  feeding  cases,  109 
in  mucous  colitis,  206 
in  nursing  mothers,  65 

a  cause  of  colic  in  child,  165 

of  constipation  in  child,  167 
treatment  of,  for  eczema  in  child, 
401 
in  nurshngs,  167 
in  older  children,  170 
in  peritonitis,  469 

not  an  index  of  intestinal  toxemia, 
162 


Constipation,  treatment  of,  166-168 
Contagious  diseases,  care  to  be  exer- 
cised in  attending,  300 
Continence  of  urine,  when  established, 

336 
Convulsions,  infantile,  a  cause  of  cere- 
l)ral  hemorrhage,  364 
of  epilepsv,  364 
chloral  in,  364 

chloroform  inhalations  in,  364 
diet  after,  364 
due  to  atelectasis,  5 1 
to  enlarged  thymus,  365 
to     gastro-intestinal     irritation, 

363 
to  phimosis,  363 
to  rachitis,  363 
to  worms,  214 
from  birth  trauma,  363 
in  acute  nephritis,  347 
in  dentition,  36 
in  pertussis,  323 

in  onset  of  acute  intestinal  infec- 
tion, 199 
of  lobar  pneumonia,  272 
management  of,  364 
uremic,  347 
Cooling  of  milk,  106 
Cooperation   of  mother    in    treatment 

of  the  children,  19 
Cord,  26.     See  Umbilical  cord. 

stump,  cauterization  of,   in  tetanus 
neonatorum,  54 
Corn  starch,  when  allowed,  130 
Cornmeal  gruel  in  the  diet  of  the  nurs- 
ing mother,  70 
Corrosive  drugs  as  source  of  gastritis, 

177 
Coryza,  recurrent,  233 

associated    witli    cardiac    disease, 
296 
Cough  in  laryngitis,  246 

chronic,  due  to  adenoids,  426 
paroxysmal,  but  not  pertussis,  323 
pharyngeal,  236 
Counterirritants   for   relief   of  conges- 
tion, 493 
Counterirritation  in  acute  gastric  indi- 
gestion, 178 
in  bronchitis,  259 
in  bronchopneumonia,  268 
in  lobar  pneumonia,  275 
in  pleurisy,  279 
Country  living  in  chlorosis,  447 
Cow's  milk.     See  Milk,  coiv's. 
Cracked  wheat,  when  allowed,  130 
Cream,  age  of,  for  infant  feeding,  83 
Alderney,  107 
centrifugal,  107 

digestibility  of  gravity  and   centrif- 
ugal, 108 
gravity,  107 
Jersey,  107 


572 


Cream  in  constipation  before  nursing, 
168 

mixtures,  155 
Crede's  ointment  in  cervical  adenitis  of 

scarlet  fever,  319,  424 
Creolin  baths  in  pemphigus,  409 
Creosote,  administration  of,  504 

in  chronic  bronchitis,  261 

in  pertussis,  325 

in  steam  inhalations,  258 
Cretinism,  385,  445 
Crisis  in  lobar  pneumonia,  273 
Croup,  catarrhal.     See  Laryngitis,  acute 
catarrhal. 

diphtheritic.       See  Diphtheria,  laryn- 
geal. 

in  bronchitis,  258 

kettle,  248 

spasmodic,  246 
Crying,  habitual,  due  to  discomfort,  27 

necessary  at  birth,  51 

use  of,  26 

varieties  of,  27 
Curds  in  stools,  due  to  too  high  proteid, 
68 
of  breast-fed,  68 
Custard,  frozen,  in  illness,  134 

when  allowed,  130 
Cyanosis  due  to  atelectasis,  51 
CycHc  vomiting,  diet  in,  472 
drugs  in,  473 

due  partly  to  rheumatic  taint,  472 
Cystitis,  351 

as  cause  of  incontinence  of  urine,  338 

rare,  in  boys,  351 


Dactylitis,  syphiHtic,  470 

tuberculous,  470 
Danger-signals  in  ether,  gas,  and  chlo- 
roform, 495 
Dark  room  in  measles,  330 
Day  terrors,  1 62 
Deaf  children,  often  regarded  as  stupid, 

422 
Deafness,  acquired,  422 
due  rarely  to  mumps,  422 
to  adenoids,  422 
to  enlarged  tonsils,  422 
to  eustachian  disease,  422 
to  middle  ear  disease,  422 
following  scarlet  fever,  320 
temporary,    in    diphtheria,    grippe, 
tonsillitis,  and    the   exanthemata, 
422 
transitory,  in  pertussis,  323 
Death    from     acute     gastro-intestinal 
infection,  191 
atelectasis  in  the  newly  born,  58 
from    persistent    hematemesis    from 
ulcer  of  the  stomach,  185 
Death-rate  due  to  measles,  330 
to  pertussis,  321 


Decubitus,  sites  of,  413 
Delicate  child,  care  of,  143-150 
definition  of,  142 
examination  of,  143 
parents  beget  delicate  children,  143 
Delphinium,  414 

Delusions,   optical,   in  intestinal  toxe- 
mia, 163 
Deming  milk  modifier,  90,  91 
Denhard  gag,  137,  428 
Dentition  as  cause  of  convulsions,  36 
of  digestive  disturbances,  36 
diet  during,  36 
disturbances  of,  36 
feeding  during,  36 
in  respiratory  diseases,  36 
in  skin  diseases,  36 
in  well  children,  36 
late,  36 
multiple,  36 
Depressed  nipples,  79 
Dermatitis    gangrenosa    a    sequel    of 

chicken-pox,  333 
Detail  in  the  treatment  of  children,  17 
Development   at  the  Babies'  Hospital 
Dispensary,  56 
percentage  of    normal   development 
in  the  New  York  Polyclinic  Out- 
patient Department,  56 
Dew  method   of  artificial  respiration, 

48 
Dextrinized  barley-water,  formula  for 
making,  124 
gruels  after  diarrhea,  196 
after  ileocoUtis,  204,  205 
Diabetes  insipidus,  350 
melUtus,  350 
diet  in,  351 
drugs  in,  351 
fatality  in,  351 
loss  of  weight  in,  351 
thirst  in,  351 
urine  in,  351 
Diacetic  acid,  absence  of,  in  glycosuria, 

350 
Diachylon  plaster  in  the  treatment  of 

decubitus,  413 
Diaper  washer,  20 
Diapers,  20 
care  of,  20 
protector  for,  20 
Diarrhea,  a  conservative  process,  193 
due  to  too  high  fat,  67,  166 
in  typhoid  fever,  459 
initial   treatment  of,   in    breast-fed, 

161 
onset  of,  160 
stopping  milk  in,  161 
Diarrheal  diseases,  etiologic  factors  in, 

187 
Diet  after  adenoid  operation,  429 
after  the  sixth  year,  132 
antidiabetic,  351 


INDEX 


573 


Diet,  antirheumatic,  in  chorea,  368        I 
during  dentition,  36 
illness,  133 
second  year,  56 

often  too  low  in  proteid,   128 
high   proteid,   in    delicate    children, 

144 
in  adenitis,  tubercular,  430 
in  anemia,  439 
in  bronchitis,  258 

recurrent,  262 
in  bronchopneumonia,  267 
in  cardiac  disease,  297 
in  constipation,  171 
in  convulsions,  364 
in  diabetes,  351 
in  diphtheria,  309 
in  endocarditis,  acute,  291 
in  epilepsy,  372 
in  erythema  nodosum,  409 
in  incontinence  of  feces,  219 
in  influenza,  452 
in  intestinal  indigestion,  163 
in  jaundice,  obstructive,  437 
in  laryngismus  stridulus,  253 
in  lobar  pneumonia,  275 
in  measles,  331 
in  mucous  coUtis,  207 
in  nephritis,  348 
in  night-terrors,  365 
in  rheumatism,  464,  466 
in  rickets,  443 
in  scarlatina,  315 
in  tardy  malnutrition,  159 
in  tuberculosis,  pulmonary,  285 
non-constipating,  after  second  year, 
172 
for  five  to  ten  years,  173 
schedule,  for  feeding,  after  the  first 
year,  129-132 
Dietetic  errors,  a  predisposing  cause  to 

rheumatism  and  endocarditis,  464 
Diificult   feeding   cases,   due   to  cow's 

milk  intolerance,  108 
Digestion  of  starch,  120,  121 

disorders  of,  due  to  dentition,  36 
Digestive  power,  best  in  morning,  159 
Digitalin  in  acute  intestinal  infection, 

199 
Digitalis,  abuse  of,  299 
administration,  504 
as  a  heart  stimulant  for  young  chil- 
dren, 277 
in  bronchopneumonia,  270 
in  cardiac  disease,  296,  298 
in  diphtheritic  paralysis,  381 
in  ileocoHtis,  202 
in  myocarditis,  293 
in  nephritis,  343 
in  scarlet  fever,  318 
use  may  be  attended  with  harm,  19 
Dilatation  of  stomach,  1 83 
causing  vomiting,  175 


Dilatation  of  stomach  jn  chronic  gas- 
tritis, 179 
in  marasmus,  154 
Diluted  food  in  bronchitis,  258 
in  bronchopneumonia,  267 
in  illness,  133 
in  scarlet  fever,  315 
in  tonsilhtis,  238 
Dilution  of  drugs,  504 
Dining  alone,  132 
Diphtheria,  antitoxin  rash  in,  307 
a  cause  of  acute  endocarditis,  307 
and  myocarditis,  293 
cause  of,  302 
cervical  adenitis  in,  302 
cool  pack  in,  302 

effect  of  antitoxin  on  membrane  in, 
304 
on  temperature  in,  304 
foul  breath  in,  302 
gargle  in,  309 
gavage  in,  302 
general  treatment  in,  309 
inhalations  in,  309 
Klebs-Loffler  bacillus  in,  302 
laryngeal,  304 

antitoxin  dosage  in,  304 
intubation  in,  312-314 
onset  of,  304 
late  giving  of  antitoxin  in,  306 
leukocytes  in,  307 
location  of  membrane  in,  302 
nasal,  230 

rectal  feeding  in,  300 
sponge  bath  in,  300 
spray  in,  309 
strophanthus,  in,  300 
strychnin  in,  309 
throat  irrigation  in,  245,  309 
transmission  by  kissing,  28 
vaporization  in,  309 
versus  streptococcus  throat,  304 
Diphtheritic    paralysis,    percentage   of 
occurrence  of,  379 
peptonized  milk  by  gavage  in,  115 
Diplegia,  384 
Directions  for  the  care  of   the   child, 

41 
Disinfection  of  the  excreta  in  typhoid 

fever,  457 
Disorders  of  speech  due  to  intestinal 

toxemia,  162 
Dispensary  patients,  feeding  of,  91 

written  instructions  for  the  feed- 
ing of,  189 
Diuretics  in  nephritis,  346 
Double  mirror  for  gymnastic  exercises, 
506 
room  for  sickness,  454 
Douche  bag  for  ear  irrigation,  421 

cold,  29 
Dover's  powder,  332 
in  bronchitis,  219 


574 


Dover's  powder  in  cough  of  broncho- 
pneumonia, 270 
in  diarrhea,  194 
in  fever,  477 
in  ileocohtis,  201 
in  laryngitis,  249 
in  rhinitis,  231 
in  typhoid  fever,  459 
with  bismuth  in  fecal  incontinence, 
219 
Drafts,  57 

Drainage  of  summer  home,  492 
Drinking  water  in  measles,  331 

with  meals,  184 
Drop  method  for  ether  anesthesia,  495 
Drugs  and  drug  dosage,  545-561 
nauseating  and  unpalatable,  502 

those  which  may  harm,  19 
use  of,  in  cardiac  disease,  296 
in  endocarditis,  291 
in     gastro-intestinal     indigestion, 

178 
in  meningitis,  375 
promiscuous  use  of,  by  family,  501 
Dry   supper   in   treatment   of  inconti- 
nence of  urine,  340 
Duodenitis   causing   obstructive   jaun- 
dice, 437 
Duration  of  tub-baths,  29 
Dust,  importance  of,  in  measles-pneu- 
monia, 330 
Dusting-powder,  26 
in  furunculosis,  412 
in  gonorrheal  vaginitis,  358 
in  granuloma,  53 
in  intertrigo,  404 
in  prickly  heat,  417 
in  vulvovaginitis,  357 
Dysarthria  due  to  intestinal  toxemia, 

'163 
Dysphagia  in  retropharvngeal  abscess, 
242 
in  tonsilhtis,  238 


Ear,  examination,  420 
pulhng,  432 
syringes,  421 
Earache,  camphor  water  in,  418 

measures  to  relieve,  418 
Eating,  bad,  57 

between  meals,  causing  loss  of  appe- 
tite, 126 
utensils,  care   of,  in   the  sick-room, 
301 
Eczema   about    a    suppurating   navel, 
26 
as  cause  of  malnutrition,  401 
associated  with  acid  urine,  401 
with  high  fat,  402 

sugar,  402 
with  recurrent  bronchitis,  401 
due  to  faulty  metabolism,  401 


Eczema  due  to  maternal  nursing,  401 
to  salivation,  220 
to  soaps,  403 
to  woolens,  403 

fresh  cow's  milk  in,  402 

intertrigo,  403 

neurotic,  404 

of  older  children,  404 

seborrheic,  406 

treatment  of,  external,  402,  403 

washing  face  in,  403 
Edema  of  larynx,  intubation  in,  310 
Education   of  mother   about   feeding, 

189 
Eggs,   excluded  in  the  diet   of   neph- 
ritics,  348 

in  delicate  children,  145 

soft-boiled,  when  allowed,  130 
Egg-water,  formula  for  making,  123 
Electricity  in  Erb's  paralysis,  386 

in  facial  paralysis,  383 

in  multiple  neuritis,  382 

in  poliomyelitis,  379 
Electrotherm    in    premature    infants, 
45,  46 

uses  of,  499 
Elixir  simplex  as  a  vehicle,  504 
Emphysema  due  to  asthma,  264 
Empty  stomach,  giving  drugs  on,  504 
Empyema,  development  of,  281 

double,  284 

encysted,  a  cause  of  obscure  eleva- 
tion of  temperature,  479 

exploration  of  chest  in,  281 

insufficient  drainage  in,  282 

irrigation  of  the  cavity,  383 

mistaken  for  tuberculosis,  280 
for  typhoid,  281 
for  unresolved  pneumonia,  28 1 

necessitatis,  284 

pocketing  of  pus  in,  283 

removal  of  tube  after  thoracotomy 
for,  283 

resection  of  a  rib  for,  281 

thoracotomy  for,  281 
Endermic  feeding,  138 
Endocarditis  a    part    of    rheumatism, 
463 

diet  in,  291 

heart  action  in,  292 

ice  cap  for,  291 

in  diphtheria,  290 

in  influenza,  290,  453 

in  rhevmiatism,  290 

in  scarlet  fever,  290 

malignant,  with  diphtheria,  293 
witli  scarlet  fever,  293 
with  tonsillitis,  293 

rheumatic,  recurrence,  296 

salicylates  for,  292 

septic,  293 
Enema  after  ileocohtis,  204 

in  cohc,  165 


INDEX 


575 


Enema  in  constipation,  170,  166 
ot   nursing  mothers,  66 
in  convulsions,  364 
in  ileocolitis,  205 
in  pneumonia,  lobar,  274 
in  typhoid  fever,  458 
initial    treatment    of    all    cases    of 

vomiting,  177 
nutrient,  141 
soapsuds,  166,  376 
standing  order  for,  166 
Energy  expended  by  a  child,  28 
Enterocolitis    a    cause    of    peritonitis, 
469 
alcohol  in,  498 
Enuresis,  338.      See    also  Incontinence 

of  urine. 
Environment,  431 

a  factor  in  artificial  feeding,  80 
in  growth  of  child,  55 
in  intestinal  diseases,  186 
in  marasmus,  153 
unfavorable,  186 
Epilepsy  a  contraindication  to  mater- 
nal nursing,  71 
bowel  function  in,  372 
bromids  in,  372 
diet  in,  372 

due  to  infantile  convulsions,  364 
fatigue  in,  372 
institutions  for,  371 
intestinal  toxemia  in,  372 
irritative  lesions  in,  372 
management  of,  371,  372 
Epiphyses,  enlarged,  441 

separation  of,  in  scurvy,  445 
Epispadias,  353 

Epistaxis,  234.     See  also  Nasal  hemor- 
rhage. 
Epitrochlear  glands,  enlarged,  in  syph- 
ilis, 390 
Epsom  salts  in  enema,  198 
Erb's  paralysis,  386 
Ergot  in  pemphigus,  378 

in  purpura,  450 
Ermold,     George,     lamp    for    calomel 

fumigations,  250 
Errors  in  feeding,  127 
Erysipelas,  461-463 
applications  for,  462 
drugs  for,  462 
feeding  in,  462 
following  vaccination,  485 

varicella,  333 
hygiene  in,  462 
in  the  newly  born,  49 
mortality  of,  461 
scarifications  for,  461 
Erythema  multiforme,  410 
nodosum,  409 
diet  in,  409 
duration  of,  409 
in  peliosis  rheumatica,  468 


Erythema  nodosum,   lead  and  opium 
f(jr,  409 
potassium  iodid  for,  409 
rheumatic  nature  of,  409 
Ether,    anesthesia    by    preference,    in 
adenoids,  428 
contraindications  for,  495 
danger  signs  of,  405 
in  cliildren,  494 
Ethyl  clilorid,  405 

Eustachian   tube,  catarrh  of,  as  cause 
(jf  persistent  deafness,  422 
due  to  adenoids,  239 
to  tonsils,  239 
infected  by  nasal  syringing,  231 
Evaporated  cream,  114 
Every-day  care  of  feeding,  56 
Ewing,  James,  quoted,  307 
Examination,  Ijefore  gymnastic  thera- 
peutics, 305 
monthly,  32 
of  delicate  child,  143 
of  ear  drum,  418 
of  patient,  first,  39 
of  throat,  239 
Exercise  as  cause  of  elevation  of  tem- 
perature     in      nervous     children, 
477 
baskets,  25 
conditions  under  which  to  be  taken, 

505 
effect  on  the  milk  of  nursing  mother, 

69 
for  correcting  postures,  5 1 2 
for  delicate  child,  149 
for  nursing  mother,  66 
in  cardiac  disease,  297 
in  cure  of  obesity,  438 
in  nephritis,  349 


pen, 


26,  37,  148,  229 


Expectorant    treatment    in    catarrhal 

croup,  248 
Expectorants    in    bronchopneumonia, 

269,  270 
Exploration  of  chest,  281 
Expression  of  milk  during  suspended 

nursing,  161 
External    auditory    meatus    in    mas- 
toiditis, 423 
Extractum  ferri  pomatum,   440.     See 

also  Iron. 
Extravasation  of    blood    in    pertussis,. 

324 
Exudate,  pleural,  278 
Eyes,  care  of,  in  measles,  331 
Eyestrain,    headache    often    the    only 

sign  of,  359 


Face  mask  in  eczema,  403 
Facial  paralysis  due  to  otitis,  382,  383 
Farina  gruel  as  a  cereal,  when  allowed, 
730 


576 


INDEX 


Parina  gruel  when  allowed,  129 
Fat   an   essential    ingredient   of    food, 
59 

as  cause  of  malnutrition,  157 

badly  borne  in  ileocolitis,  205 

diarrhea  due  to,  95 

excess  of,  in  food,  signs  of,  95 

function  of,  60 

high,   occasional  cause   of  constipa- 
tion, 169 

in  proprietary  foods,  117 

indigestion,  95 

a    factor   in    the    constipation    of 

bottle-fed  babies,  169 
signs  of,  95 

inunctions,  138 

limit  of,  for  older  children,  171 

low,  an  occasional  cause  of  consti- 
pation, 167 

where  found,  60 
Fatigue  a  cause  of  fever,  478 
of  headache,  359 

in  chorea,  367 

in  epilepsy,  372 
Faucitis,  235 

treatment  of,  236 
Fecal    impaction     causing     intestinal 
obstruction,  210 

masses  a  cause  of  fissure,  213 
Feces,  incontinence  of,  218 

starch  converting  enzyme  in,  121 
Feeding  after  diarrhea,  194 
first  year,  128-132 
ileocolitis,  23 
vomiting,  193 

artificial,  80-98 

defective,  a  cause  of  tardy  malnu- 
trition, 159 

forced,   in    tuberculosis  of  children, 
285,  471 

frequency  of,   in  chronic   ileocohtis, 
205 

in  acute  gastro-indigestion,  178 

in  delicate  children,  144,  145 

in  erysipelas,  462 

in  gastritis,  chronic,  179 

in  illness,  art  of,  134 

in  malnutrition  of  infants,  157 

in  marasmus,  !54,  155 

in  premature  infants,  47 

in  sepsis,  49 

in  sprue,  224 

in  stomatitis,  222 

in  tonsillitis,  238 

in  typhoid  fever,  457,  458 

methods,  faulty,  a  cause  of  diarrheal 
diseases,  187 
instructions  in,  for  poor,  189 

of  fuU  milk,  92 

substitute,  Chapin  dipper  for,  85 
condensed  milk  and,  92 
diluting  milk  in,  82 
for  dispensary  patients,  91 


Feeding,  substitute,  full  milk,  92 
home  modification  in,  93 
intervals  in  colicky  babies,  165 
laboratory  feeding,  89 
milk  adaptation  in,  94-98 
modifying  milk,  81 
number  of  feedings,  85-88 
whey  and  cream  mixtures  in,  86 
through  skin,  138 

too  frequent,  a  cause  of  loss  of  appe- 
tite, 125 
Fetor  of  breath  in  noma,  224 
Fever  in  acute  illnesses,  475 

in  chronic    discharging   ear  case,    a 

sign  of  mastoiditis,  423 
in  otitis,  419 

persistent,  due  to  intestinal  toxemia, 
162 
Finger  sucking,  432 
Fireplace  as  ventilator,  43 
Fish,  when  allowed,  131 
Fissures  at  angle  of  mouth,  226 
of  anus,  213 
of  lips,  226 

of  rectum  a  cause  of  constipation, 
170 
Flat  chest,  causes  of,  511 
exercises  for,  516-518 
rare  in  infants,  511 
Flat-foot,  examination  for,  543 
exercises  for,  544 
massage  for,  544 
shoes  for,  545 
Floor,  playing  on,  147 

sitting  on,  a  cause  of  colds,  228 
Florida  for  nephritis  cases,  500 
Fluid  in  the  chest,  279 
Food,  adaptation  of,  60 

assimilation,   key  to  infant  feeding, 

56,  60 
decomposed,  a  cause  of  gastric  indi- 
gestion, 177 
for  premature  babies,  47 
forcing,  128 
fried,  132 
infected,  a  cause  of  summer  diarrhea, 

186 
properties  and  ingredients,  59 
proprietary,  a  cause  of  rickets,  442 

containing  alcohol,  363 
quantity  of,  at  a  feeding,  127 
temperature  of,  in  stomatitis,  221 
too  concentrated,  a  cause  of  consti- 
pation, 171 
too  strong,  signs  of,  88,  94 
too  weak,  signs  of,  88,  94 
unsuitable,  a  cause  of  acute  gastric 

indigestion,  177 
utensils,  care  of,  in  congenital  syphi- 
lis, 389 
in  quarantine,  301 
Forceps,  laryngeal,  254 
Foreign  bodies  in  larynx,  removal  of,  254 


577 


Foreign  bodies  in  nose  a  cause  of  nasal 

catarrh,  232 
Foreskin,  incision  of,  in  paraphimosis, 

354.     See  also  Circumcision. 
Formalin  in  sprue,  224 
Formulce  for  condensed  milk  mixtures, 
93 
for  feeding  dispensary  patients,  92, 
93 
well  babies,  cream  and  milk  mix- 
tures, 84,  85 
for  making  barley  jelly,  123 
barley-water,  123,  124 
beef-broth,    beef-juice,   chicken- 
broth,  123 
dextrinized  barley-water,  124 
egg  albumin  water,  123 
imperial  granum  water,  124 
junket,  125 
mutton  broth,  123 
oatmeal  water,  124 
wheat  jelly,  123 
whey,  124 
for  top-milk  mixtures,  87 
for  whole  milk  mixtures,  92 
Foul  breath  in  diphtheria,  302 
in  noma,  224 

in  ulcerative  stomatitis,  221 
Fowler's  solution  in  chorea,  369 

susceptibility  to,  370 
Freeman's  pasteurizer,  1 1 1 
Fresh  air,  difficult  to  secure,  57 
for  nursing  mother,  66 
in  anemia,  439 
in  bronchitis,  258 
in  bronchopneumonia,  267 
in  delicate  children,  146 
in  erysipelas,  462 
in  growth  of  child,  57 
in  lobar  pneumonia,  274 
in  marasmus,  153 
in  pertussis,  328 
in  premature  infants,  45 
in  tuberculosis,  286 
cow's  milk  in  eczema,  402 
in  scurvy,  445 
Friedreich's  ataxia,  exercises  for,  527 
Fright  causing  vomiting,  176 
Fruit  during  lactation,  65 

when  allowed  in  diet,  130,  131 
Fumigation  after  grippe,  454 
Furnishings  of  sick-room,  43 
Furniture  for  children,  510 
Furunculosis,  411 
after  varicella,  333 
treatment  of,  411,  412 

Gain  in  weight,  amount  of,  in  success- 
ful maternal  nursing,  67 
normal,  under  one  year,  144 
Galvanocautery     in     cure     of    hyper- 
trophy of  tonsils,  240 

37 


Gargles  in  diphtheria,  309 

Garhc,    infusion   of,    in   thread-worms, 

215 
Gas-ether  anesthesia,  495 
Gastritis,  acute,  beginning  grippe,  453 
causes  of,  176 
treatment  of,  177 
chronic,  179 

barley-water  in,  1 79 
cause  of,  179 
following  acute,  178 
treatment  of,  179 
Gastro-enteritis  as   cause   of   suppres- 
sion, 337 
cereals  to  replace  milk  in,  120 
complicating  erysipelas,  462 

pertussis,  323 
onset  of,  191 
symptoms  of,  191 
termination  of,  193 
treatment  of,  191 
Gastro-enterostomy  in  congenital  py- 
loric stenosis,  86 
Gastro-intestinal  intoxication,  191 

irritation  as  cause  of  convulsions,  363 
Gavage,  134-136 
amount  of,  137 
frequency  of,  137 
in  cleft-palate,  399 
in  diphtheria,  310 
in  hare-lip,  398 
in  lobar  pneumonia,  277 
in  marasmus,  152,  153 
in  meningitis,  375 
in  persistent  vomiting,  1 78 
in   post-diphtheritic    paralysis,    380, 

381 
in  sepsis,  49 

in  tetanus  neonatorum,  54 
Genitals,  female,  357 

uncleanUness   of,   in  difficult    uri- 
nation, 336 
male,  352 
Geographical  tongue,  227 
Giant  hives,  387 
Gin  in  colic,  166 
Ginger-ale,  134 

Gingivitis  in  typhoid  fever,  457 
Girls,  hysteria  in,  360 

masturbation  in,  433 
Glands  of  neck  in  diphtheria,  302 
in  tonsillitis   237 
retropharyngeal,  suppuration  of,  242. 
See  also  Adenitis,  cervical. 
Glandular  fever,  47 1 
Glass-tube  for  taking  iron,  504 
Glasses  for  relief  of  headache,  359 
Glauber's  salt  in  gastro-intestmal  m- 

fection,  192 
Glycerin  suppository,  166 

adjuvant  in  oil  treatment  of  con- 
stipation, 174 
Glycosuria,  diabetic,  350 


578 


INDEX 


Glycosuria,  dietetic,  349 

temporary,  349 
Gonorrhea  in  female,  357 

bacteriologic    examination    before 
discharge  of  case  of  vaginitis,  358 
method  of  infection  of,  357 
treatment  of,  358 
in  male,  355 
in  nursery  maids,  23 
Good  food,  most  important  factor  in 

nutrition,  55,  56 
Goose  oil  rub,  139,  146,  158 
in  tetany,  367 
in  tuberculosis,  287,  371 
Granuloma,  26,  53 
Granum-water,  179 

after  gastro-intestinal  infection,  192 
formula  for,  124 
Green  vegetables  in  diet  of  child,  145 

in  rheumatism,  464 
Grindelia  robasta  in  ivy-poisoning,  411 
Grippe,  452.     See  also  Influenza. 
Ground-floor,    child    to    sleep    above, 

492 
Growing  pains  a  part  of  rheumatism, 

463 
Growth  of  child  as  regards  his  future, 

55 
Gruels.     See  Cereal  gruels. 
Gums,  bleeding,  in  ulcerative  stomati- 
tis, 453 
Gymnastic  therapeutics,  505-544 

adaptation   to   practical   ends   in, 

507 
anterior  poUomyelitis  treated  by, 

541 
breathing  in,  513 
congenital  ataxias  treated  by,  526 
constipation  treated  by,  539 
duration  and  frequency  of  treat- 
ments in,  501-506 
exercises  for  correcting  bad  pos- 
tures, 512 
flat  chest,  exercises  for,  516-518 
for  Friedreich's  ataxia,  527 
for  hereditary  cerebellar  ataxia, 
527 
flat-foot  treated  by,  543 
general  considerations  in,  509 
kyphosis  treated  by,  518,  519 
period  of  treatment  in,  507 
posture  and  breathing  in,  506 
scoliosis  treated  by,  521 
Gyrospasm,  365 
in  idiots,  366 


H.\BiT  cough,  255 
spasm,  370 
diet  in,  371 
drugs  in,  371 
related  to  chorea,  371 
to  rheumatism,  371 


Habits  of  bowel  evacuation,  166 
of  ear  pulling,  432 
of  masturbation,  432 
of  self -entertainment,  432 
of  sleep,  432 
of  thumb-sucking,  432 
to  be  discouraged,  432 
to  be  encouraged,  432 
Hands,  care  of,  after  diapering,  20 
Hare-lip,  398 
feeding  in,  398 
operation  for,  398 
Hay-fever,   a  cause  of    nasal  catarrh, 

232,  263 
Head  covering  a  cause  of  colds,  228 
nodding,  365 

position   of,  in  retropharyngeal   ab- 
scess, 242 
rest  for  preventing  decubitus,  413 
Headache  a  possible  sign  of  meningitis, 
359 
due  to  eye-strain,  359 

to  intestinal  indigestion,  359 
to  nitroglycerin,  277 
habitual,   an  evidence   of  intestinal 

toxemia,  162 
in  malaria,  359 
in  nephritis,  359 
in  onset  of  acute  infections,  359 
in  pneumonia,  359 
in  scarlet  fever,  359 
Hearing,  acuteness,  in  early  months,  422 

age  established,  422 
Heart,  action  of,  in  acute  endocarditis, 
292 
in  myocarditis,  294 
in  post-diphtheritic  paralysis,  380 
disease,  congenital,  299 
length  of  life  in,  299 
manner  of  death  in,  299 
treatment  of,  299 
valvular,  296-299 

associated  with  chorea,  296 
with  recurrent  bronchitis,  296 
with  tonsillitis,  296 
conduct  of  life  in,  296,  297 
diet  in,  296 
digitahs,  298 
exercise  in,  296 
origin  of,  in  rheumatism,  296 
prognosis  in,  297 
sugar  eating  in,  296 
treatment  of,  296-299 
failure  in  diphtheria,  306 
rest,  293,  295,  298 
stimulants,  299 
abuse  of,  299 
in  pneumonia,  270,  276 
indications  for,  299 
Heat,  dry,  in  nephritis,  346 
in  pain  of  neuritis,  382 
therapeutic  applications    of,   498, 
499 


579 


Height,  significance  of,  34 

table  of,  34 
Hematemesis  due  to  Henoch's  purpura, 
183 
to  swallowing  blood,  183 
to  ulcers,  183,  184 
in  cyclic  vomiting,  472 
of  newly  born,  183 
persistent,   an  evidence  of   ulcer  of 
stomach,  185 
treatment  of,  185 
Hematoma  of  sternomastoid,  398 
Hemiplegia,  384 
Hemophilia,  450 

hereditary  transmission  in,  431 

in  hemorrhagic  diseases  of  the  newly 

born,  54 
treatment  of,  450 
Hemorrhage,  cerebral,  due  to  convul- 
sions, 364 
from  stomach,  183.     See  also  Hema- 
temesis. 
meningeal,  causing  cerebral  palsy,  383 
Hemorrhagic    diseases    in    the    newly 
born,  53 
treatment  of,  54 
Hemorrhoids  rare  in  children,  218 
Hereditary  cerebellar  ataxia,  527 
Heredity  and  environment,  431 
as  factor  in  posture,  511 
in  growth  of  a  child,  55 
in  hemophilia,  450 
in  hysteria,  360 
Hernia,  inguinal,  395 
causes,  395 
occurrence,  395 
operation  for,  395 
trusses  for,  395 
strangulated,  causing  intestinal  ob- 
struction, 210 
umbilical,  396 

treatment  of,  396 
ventral,  397 

treatment  of,  397 
Herniotomy,  395 

Hiccough    due  to  distention  of   stom- 
ach, 387 
High  fat  after  diarrhea,  195 

mixtures  in  constipation,  171 
proteid  diet  for  child  in  school,  57 
in  malnutrition,  158 
Hirt,  quoted,  368 
History,  family,  importance  of,  39 

taking,  39 
Hives,  407.     See  also  Urticaria. 
Hoarseness  in  congenital  syphilis,  390   I 
Holt's  croup-kettle,  248 

milk-set,  76 
Hominy,  when  allowed,  130 
Honey  and  borax  for  sprue,  224 
Hot  air,  use  of,  499 

and  cold  baths  in  asphyxia  of  newly 
bom,  48 


Hot  batli  for  acute  gastro-intestinal  in- 
fection. 191 
in  nej^hritis,  346 
in  tetany,  336 

to  bring  out  measles-rash,  331 
uses  of,  498,  499 
fomentations  in  mumps,  334 
irrigation  of  throat,  241 

use  of,  498,  499 
packs  in  nephritis,  346 

uses  of,  498,  499 
poultices,  use  of,  498,  499 
stupes  in  colic,  165 
in  ileocolitis,  202 
in  retention,  337 
use  of,  498,  499 
Hot-water  bag  in  acute  gastro-intestinal 
infection,  191 
in  earache,  418 
use  of,  498,  499 
Hot-water  douche  in  earache,  418 
Human     milk,     percentage     composi- 
tion of,  67.     See  also  Milk,  human. 
Hutchinson's  teeth,  391 
Hydrocele,  356 

Hydrocephalus,  chronic  internal,  377 
Hydrochloric  acid,  126,  184,  437,  458 
Hydrogen  peroxid,  218,  222,  233,  354 
Hydronephrosis  as  cause  of  intestinal 

obstruction,  210 
Hydrotherapy  in  typhoid  fever,  460 
Hyperpyrexia  in  ulcerative  stomatitis, 

221 
Hypnotics,     duration    of    administra- 
tion, to  children,  382 
Hypodermic  feeding,  138 

stimulation,  277 
Hypophosphites,  syrup  of,  164,  288,  430 
Hypospadias,  353 
Hysteria,  attacks  of,  362 
environment  in,  360 
heredity  in,  360 
treatment  of,  361 


Ice-bag  in  adenitis,  424 

in  appendicitis,  211 

in  convulsions,  364 

in  endocarditis,  291 

in  glandular  fever,  471 

in  headaches  due  to  fever,  359 

in  mastitis,  79,  52 

in  nasal  hemorrhage,  234 

in  pericarditis,  290 

in  poliomyehtis,  378 

in  quinsy,  241 

in  typhoid  fever,  461 

uses  of,  499 
Ice-cream  in  illness,  134 

when  first  allowed,  131 
Ice-stations,  municipal,  188 
Ichthyol  in  albolene  for  chronic  rhini- 
tis. 233 


58o 


INDEX 


Ichthyol  in  olive-oil  as  an  inunction  for 
chicken-pox,  333 
ointment  in  adenitis,  333,  424 
in  contagious  impetigo,  408 
in  eczema,  403 
in  erysipelas,  49,  462 
in  fissure  of  anus,  214 
of  lips,  226 
of  mouth,  226 
in  furunculosis,  411 
in  German  measles,  333 
in  hemorrhoids,  218 
in  inflammation  of  anus,  213 
in  mastitis  of  newly  born,  52 
in  ulcers  of  nasal  septum,  234 
Icterus,  437 

neonatorum,  50 
Idiocy,  384 

after  convulsions,  363 
with  gyrospasm,  366 
Ignorance  an  important  factor  in  poor 

feeding,  57 
Ileocolitis,  acute,  bacteriology  of,  200 
blood  in  stools  of,  200 
colon  flushing  in,  202 
constipation  after,  204 
diet  in,  200 
drugs  in,  201 
duration  of,  200 
during  convalescence,  203 
feeding  during  attack,  200 
following    acute    gastro-intestinal 

infection,  193.  200 
pathologic  findings  in,  199 
prostration  in,  200 
starch  injections  in,  203 
stools  in,  200 
temperature  in,  200 
tenesmus  in,  200 
treatment  of,  201-204 
chronic,  204 

causing  malnutrition,  204 
following  acute,  204 
starch  intolerance  in,  205 
treatment  of,  205 
Illness,  acute,  contraindicating  mater- 
nal nursing,  7 1 
Imitation  of  parents  mistaken  for  he- 
redity, 360 
strong,  in  child,  360 
Immunity,  duration  of,  insured  by  diph- 
theria antitoxin,  308 
Imperial  granum -water,  119 
formula  for  making,  124 
Impetigo  contagiosa,  408 
Inadequate  diet  of  second  year,  56 
Inanition  and  death-rate,  80 

fever  comphcating   sepsis  of   newly 
born,  49 
Incisor  teeth,  time  of  appearing,  35 
Incontinence  of  feces,  218 
of  urine,  causes  of,  338 
in  cystitis,  351 


Incontinence   of   urine,   treatment   of, 
338,  339 
when  abnormal,  336 
Incubators,  baby,  defective  air-supply 

in,  45 
Indicanuria  in  persistent  headache,  359 
not  always  present  in  intestinal  indi- 
gestion, 162 
Indigestion,  acute  intestinal,  160,  161 
onset  of,  160 
resuming  milk  in,  161 
stopping  milk  in,  161 
treatment  of,  161 
as  cause  of  anemia,  438 
of  night-terrors,  365 
of  urticaria,  407 
associated  with  angioneurotic  edema, 
388 
with  pharyngitis,  236 
gastric,  acute,  177 
causes  of,  177 
treatment  of,  177 
intestinal,  predisposing  to  diarrhea  in 

summer,  160 
predisposing  to  acute  intestinal  in- 
fection, 197 
Individual,  treatment  of,  42 
Indoor  airing,  37,  58,  147 
Infantile  atrophy,  151 

convulsions  common  in  rickets,  441. 
See  also  Convulsions,  infantile. 
Infectious   diseases   causing   vomiting, 

176 
Inflation  of  lungs  in  asphyxia,  48 
Influenza,  452 

as  cause  of  endocarditis,  290 
danger  of  complications  in,  452 
disinfection  after,  454 
preceding  otitis,  418 
treatment  of,  452,  453 
Inguinal  adenitis,  424 
hernia,  395 

reduction  of,  395.     See  also  Her- 
nia, inguinal. 
Inhalation  of  irritating  gases,  254 

of  steam  a  cause  of  laryngitis,  253 
Inhalations  in  asthma,  265 
in  bronchitis,  258 
in  bronchopneumonia,  268 
in  diphtheria,  309 
in  pertussis,  328 
Initial  loss  in  weight,  31 
Institutions  a  factor  in  artificial  feed- 
ing, 80 
for  epileptics,  372 
for  mentally  defective,  383 
Instructions  for  mothers,  92 
Insufflations  in  pertussis,  324 
Insufflator  for  spreading  dusting-pow- 
der, 357 
Intercostal  neuralgia,  iodin  in,  494 
Intermittent    treatment    in    chlorosis, 
441 


58i 


Intermittent  treatment  in  chorea,  369 
in  pertussis,  327 
in  recurrent  broncliitis,  262 
in  syphilis,  with  iodids,  392 
Intertrigo,  403 

Intestinal  antiseptics  in  typhoid  fever, 
458 
diseases,  acute,  effect  of  chmate  on, 
500 
etiology  of,  187 
prevention  of,  186 
treatment  of,  190 
hemorrhage  rare  in  typhoid  fever,  461 
infection  a  cause  of  obscure  eleva- 
tion of  temperature,  479 
acute,  197 

active  type,  197 
inactive  type,  197 
treatment  of,  197 
obstruction,  209,  210 

causing  vomiting,  176 
parasites,  214-216 
perforation  in  typhoid  fever,  461 
putrefaction  as  cause  of  colic,  164 
toxemia,  headache  in,  359 
in  asthma,  266 
in  chronic  eczema,  404 
in  epilepsy,  372 
Tntraspinous  injection  of  drugs,  377 
Intubation,  310 

in  catarrhal  croup,  246 
in  diphtheria,  312 
in  edema  of  larynx,  312 
in  foreign  bodies,  254 
in  pharyngitis,  314 
in  retropharyngeal  abscess,  314 
indications  for,  311 
method,  31 1 

plugging  tube  with  membrane,  314 
results  from,  313 
with  use  of  antitoxin,  314 
Intussusception,  211 

causing  intestinal  obstruction,  29 
mortality  of,  211 
reduction  of,  211 
stools  in,  211 
Inunctions  of  cacao-butter,  139 
of  goose  oil,  139 
of  ichthyol  ointment  in  chicken-pox, 

333 
of  lard,  139 

of  mercurial  ointment,  389 
of  olive  oil,  139 
Inverting  patient  in  laryngismus  strid- 
ulus, 252 
lodid  of  potash,  administration,  503 
in  erythema  nodosum,  409 
in  hydrocele,  356 
in  multiple  neuritis,  382 
in  peliosis  rheumatica,  469 
in  pleurisy,  280 
in  poliomyeUtis,  378 
unpalatable,  503 


Iodids,  392 

lodin  as  counterirritant,  493 
in  intercostal  neuralgia,  494 
in  pleurisy,  280 
in  ringworm,  416 

of  scalj),  415 
injection  in  spina  bifida,  397 
Ipecac,  administration  of,  503 
in  bronchitis,  260 
in  catarrhal  laryngitis,  248 
in  faucitis,  236 
in  pneumonia,  270 
syrup  of,  264 
unpalatable,  503 
wine  of,  325 
Iron  and  ammonium  citrate,  367,  440 
and    qutnin   citrate,    126,    159,    164, 

287,  288,  439 
chloride,  tincture  of,  administration 
of,  504 
in  incontinence  of  feces,  .219 
citrate,  439,  440 
content  of  foods,  table  of,  by  Bunge, 

439 
extractum  ferri  pomatum,  287,  371, 

430 
in  anemia,  440 
in  cardiac  disease,  298 
in  chlorosis,  441 
in  hysteria,  362 
in  neuritis,  382 
in  persistent  adenitis,  425 
in  poor  appetite,  126 
in  tetany,  367 

in  tuberculous  adenitis,  430 
iodid  of,  in  malnutrition  of  syphih- 
tic  origin,  393 
Irrigation  of  throat,  245,  319 
in  diphtheria,  309 
in  peritonsillar  abscess,  245 
in  quinsy,  241 
in  scarlet  fever,  245 
in  tonsiUitis,  238 
Irritants  a  cause  of  gastritis,  177 
Ischiorectal  abscess,  218 
Isolation  of  sick,  300 
Italians  and  rickets,  441 
Itch,  412.     See  also  Scabies. 
Itching  of  anus  due  to  pin-worms,  215 

of  skin  in  chicken-pox,  337 
Ivy-poisoning,  410 


James'  tubes  for  cases  of  empyema,  280 
Jaundice  of  newlyborn,  50 
obstructive,  437 
stools  in,  437 
treatment  of,  437 
urine  in,  437 
Jaw  deformity  due  to  sucking  habit, 

432 
Jersey  cream,  percentage  of  fat  in,  83, 
107 


582 


INDEIX 


Joint-rheumatism,  463 

Junket   formula  for  making,  125 

in  ileocolitis,  205 

in  illness,  134 

when  allowed,  131 

Kaolin,  cataplasm  of,  319,  424 

Key-note  position,  525 

Kidney,  sarcoma  of,  a  cause  of  intesti- 
nal olDstruction,  210 

Kilmer  belt  for  whooping-cough,  328 
croup-kettle,  347,  499 

Kindergarten  chair,  510 

King,  experiments  on  milk  contamina- 
tion, 100 

Kissing,  a  bad  practice,  28 
in  congenital  syphilis,  389 
transmission  of  disease  by,  28 

Klebs-Loffler     bacillus    causing    diph- 
theria, 302 

Knee-jerks,     increased,     in     intestinal 
toxemia,  163 

Knotted  towel   to    insure    sleeping   on 
side,  340 

Kyphosis,  exercises  for,  518 
rachitic,  444 

Laboratory  feeding,  89 

Laborde's  method  of  artificial  respira- 
tion, 48 

Lactalbumin  of  cow's  milk,  99 

Ladder  exercises   for   ataxic   children, 
535 

Lakewood   for   convalescent    patients, 
500 

Lamb  chop,  when  allowed,  130 

Lancing  gums  for  teething,  36 

Lanolin,  78 

Laparotomy,  indications  for,  in  tuber- 
culous peritonitis,  469 

Lard,  139 

inunctions  of,  371 
in  malnutrition,  158 

Larkspur  in  pediculi,  414 

Laryngismus  stridulus,  251 
adenoids  in,  251 
diagnosis  of,  251 
in  lymphatic  diathesis,  449 
in  rickets,  251 

treatment  of,  252,  253 

Laryngitis,  acute  catarrhal,  246 
intubation  in,    310 
membranous,  304 
traumatic,  253 

Larynx,  abscess  of,  in  diphtheria,  244 
foreign  bodies  in,  254 
obstruction  of,  254 
post-diphtheritic  paralysis  of,  379 
removal  of  foreign  bodies  from,  254 

Late  teething,  36 

Lavage,  180 

amount  of  fluid  to  be  used,  181 


Lavage,  dangers  of,  180 
frequency,  180 

in  dilatation  of  the  stomach,  184 
in  gastritis,  179 
in   gastro-intestinal    infection,    191, 

192 
in  marasmus,  153 
in  poor  appetite,  182 
in  repeated  vomiting,  177 
in  sugar-indigestion,  95 
indications  for,  180 
method  of,  180 

rarity  of  its  causing  bleeding,  185 
Laxatives  after  diarrhea,  197 
Lead  and  opium  wash  in  antitoxin  urti- 
caria, 307 
in  erythema  nodosum,  409 
in  orchitis,  356 
in  rheumatism,  467 
neuritis,  381 
Leaking  breasts,  77 

Leg-rubl)ing,    433.     See    also    Mastur- 
bation. 
Legume  diet,  285 
Lemonade  in  typhoid  fever,  457 
Leukemia,  438 
Leukocytosis  in  diphtheria,  307 

in  fatal  cases  of  diphtheria,  307 
Lice,  413 
Lime-water,  70 
Lips,  fissures  of,  226 
Lithemic  diathesis  and  asthma,  263 
Low  fluids  in  weaning,  7 1 

milk  diet  for  intestinal  indigestion, 
163 
Lumbar  puncture,  376 

disinfection  before,  376 
in  diagnosis   374 
in  treatment,  374 
method  of  doing,  376 
site  for,  376 
Lymphatic   glands,  enlarged,  in  diph- 
theria, 237 
in  tonsillitis,  237 


Magnesia  in  bottle-fed,  169,  170 
in  chronic  ileocolitis,  205 
in  colic,  166 
in  fissure  of  anus,  2 1 4 
in  glandular  fever,  471 
Magnesium  citrate  in  acute  endocardi- 
tis, 291 
in  appendicitis,  211 
in  mastitis,  52 
in  typhoid  fever,  458 
Malaria  as  cause  of  multiple  neuritis, 
381 
blood  in,  454 
diagnosis   often   made   in   intestinal 

toxemia,  162 
in  delicate  child,  143 
Plasmodium  of,  454 


INDEX 


583 


Malaria,  (|uinin  in,  455 
recurrence  in,  466 
spleen  in,  454 
temperature  in,  454 
Male  fern,  oleoresin  of,  in  tape-worm, 

216 
Malignant      disease      contraindicating 

nursing,  71 
Malnutrition  after  pertussis,  323 
as  cause  of  chronic  rhinitis,  222 
due  to  exclusive  milk  diet,  129 
to  ileocolitis,  204 
to  stomatitis,  222 
from  cutting  down  proteid  in  consti- 
pation, 169 
gavage  in,  137 
in  infants,  156 
tardy,  non-syphilitic,  158 
of  syphilitic  origin,  392 
years  to  get  results  in,  18 
Malt  in  tuberculous  adenitis,  430 

soup,  98,  157 
Malted  foods  a  cause  of  malnutrition, 
157 
milk  in  constipation  of  nurslings,  168, 
169 
in  fissure  of  anus,  214 
in  intestinal  indigestion,  164 
in  mucous  colitis,  207 
with  cocoa,  1 72 
Maltose,  118 

foods  only  carbohydrates,  118 
Mammary  abscess,  52 

due  to  cracked  nipples,  79 
in  infants,  52 
Marasmus,  150 

due  to  chronic  gastritis,  179 
in  tenements    151 
Massage  for  constipation,  169 
in  Erb's  paralysis,  386 
in   hematoma  of  the  sternomastoid, 

398 
in  multiple  neuritis,  383 
in  poliomyelitis,  379 
of  abdomen  to  relieve  intestinal  ob- 
struction, 210 
of  breasts,  71,  78 
Mastitis,  acute,  79 

a  contraindication  to  nursing,  79 
in  newly-born,  52 
in  young  girls,  52 
treatment  of,  79 
Mastoiditis,  423 
Masturbation,  433 
brace  for,  434 
circumcision  for,  434 
cure  of,  434 

due  to  leg  rubbing,  434 
to  neurotic  habit,  433 
to  phimosis,  433 
to  urine  being  acid,  433 
more  frequent  in  girls,  433 
night  watch  in,  435 


Maternal  nursing,  62.     See  also  Nurs- 
ing mother. 
ability  more  frequent   nowadays, 
62 

advantages  of  regularity  in,  66 

after  twelve  months,  70 

air  and  exercise  in,  66 

amount  jjnjper  for  nursing,  68 

bad  effect  of  too  long  continued, 
129 

beginning  bottles  in,  66 

best  age  for,  64 

bowel  function  in,  65 

care,  of  nipples  in,  72 

conditions  forbidding,  71 

defmite  times  for,  43 

diet  in,  64 

feasible  duration  of  lactation,  63 

frec|uency  of,  73 

interfered  with,  by  rhinitis,  229 

length  of  time  for  each  nursing,  68 

management     of    abnormal    milk 
conditions,  69,  70 

menstruation  in,  71 

mixed  feeding,  70 

prevented  by  stomatitis,  221 

regularity  in,  66 

signs  of  successful,  67 
of  unsuccessful,  67 

temporary  discontinuance  of,  71 

too  rapid,  69 

too  weak  milk  in,  69 

unfavorable  factors  for,  71 

water  before,  in  fever,  133 

weaning,  71 
Matzoon  in  typhoid  fever,  451 
Meals,  definite  times  for,  43 

number  of,  in  second  year,  172 
Measles,  330-332 
care  of  ears  in,  332 

of  eyes  in,  33,^ 
cause  of  otitis,  418 
clothing  in,  331 
cough  in,  332 

danger  of  bronchopneumonia  in,  330 
death-rate  in,  330 
delayed  rash  in,  331 
diet 'in,  332 

examination  of  ears  in,  332 
frequency  of,  330 
fresh  air  in,  330 
German,  333 
in  institutions,  330 
inunction  in,  331 
moist  air  in,  332 
old-fashioned  treatment  of,  330 
percentages  of  susceptibility  in,  323 
quarantine  in,  332 
rhinitis  of,  230 
treatment  of,  331,  332 
Meat  eating  in  chorea,  368 

in  chronic  diffuse  nephritis,  348 

in  rheumatism,  464 


584 


Meckel's  diverticulum  a  cause  of  intes- 
tinal obstruction,  210 
Mellin's  food  in  constipation,  168,  170 

in  fissure  of  anus,  2 1 4 
Membrana    tynipani,    examination   of, 
in  earache,  418 
paracentesis  of,  480 
Meningitis,  convulsions  in  onset  of,  363 
epidemic  cerebrospinal,  373 
prognosis  in,  373 
recovery  from,  374 
simple  acute,  373 
tubercular,  373 
Menstruation  and  maternal  nursing,  71 
Menthol  hniment  for  urticaria,  408 
in  articular  rheumatism,  467 
in  erythema  multiforme,  410 
in  ointment  for  eczema,  405 
in  rhinitis,  230 
Mercurv,  392 

administration  of,  389,  390,  391,  392 
albuminate  of,  389 
bichloride  of,  389 
salicylate,  389 

supplementing    interval    treatment, 
391 
Method,  necessity  of,  in  care   of   child, 

42 
Micturition,  first,  335 

difficult  and  painful,  336 
Mid-day  nap,  43 

for  delicate  children,  149 
for  nursing  mother,  66 
in  cure  of  hysterical  children,  362 
in  tardy  malnutrition,  158 
Miliaria,  416 

Milk,  a  cause  of  constipation,  169,  171 
a  factor  in  acute  intestinal  diseases, 

188 
action  of,  on  stomach  secretions,  61 
certified,  103 

contaminated   by   cow's   udder   and 
body,  101 
by  manure,  99 
by  openings  in  pails,  101 
by  pouring,  100 
by  standing,  100 
by  utensils,  100 
cooked,  a  cause  of  constipation,  169 
cow's,  98-107 
adaptation  of,  81 
by  alkalies,  95 
by  cereal  gruels,  97 
by  malt  soup  extract,  98 
by  peptonizing,  97 
by  sodium  citrate,  96 
by  whey  feeding,  96 
bottled,  103 

care  after  sterilizing  and  pasteuriz- 
ing, 112 
casein  of,    a  cause  of  intolerance 

for,  108 
cooHng,  106 


Milk,  cow's,  cost  of  producing  clean, 
103 
curds  of,  96,  97 

effect  of  alkalies  on,  61 
of  cereal  gruels  on,  97 
of  peptonizing  on,  97 
of  sodium  citrate  on,  96 
of  sterilization  on.  111 
fat  of,  adaptation  of,  95 
affected  by  cow's  diet,  98 
child's  digestive  capacity  for,  95 
percentage  of,  compared  to  that 

of  human  milk,  81 
modification  of,  82 
lactalbumin  of,  99 

eft'ect  of  sterilization  on,  1 1 1 
lactose  of,  98 

modification  of,  82 
lime  salts,  effect  of  sterilization  on, 

111 
mixtures,     resuming,     after    con- 
densed milk,  108 
with  cream,  84,  85 
modification  of,  82 

by  cream  and  milk  mixtures,  84, 

85 
by  dilution,  82 

and  adding  lactose,  83 
by  laboratory  methods,  89 
by  top-milk  methods,  87 
by  skimmed  milk  mixtures,  85 
peptonization  of,  115,  116 
proteid  of,  a  cause  of  colic,  165 

adaptation  of,  95 
reasons  for  using,  in  artificial  feed- 
ing, 81 
skimmed,   a  substitute  for  whole 
milk  in  fat  incapacity,  145 
in  rectal  feeding,  141 
mixtures  of,  85 
solids  of,  98 
crusts,  405 

dairy,  percentage  value  of,  81 
diet,  exclusive,  128 
in  nephritis,  343 
in  scarlet  fever,  315 
drinking  excessive,  cause  of  loss  of 

appetite,  125 
examination  in  breast  fed,  68 
food  constituents  of,  61 
for  traveling,  1 16 
general  properties  of,  61 
habit,  145 

and  loss  of  appetite,  126 
and  malnutrition,  126 
herd,  98 
human,  composition  of,  75 

affected  by  sore  nipples,  78 
exact  reproduction  of  impossible^ 

56 
examination  of,  75 
fat  of,    75 
microscopic  examination  of,  76 


INDEX 


585 


Milk,  human,  percentage  composition 
of,  81,  117 
percentages   of  food    constituents 
of,  75 

importance  of,  in  diet  of  child,  144 

in  acute  intestinal  infection,  199 

in  diet  of  the  nursing  mother,  65 

in  ileocolitis,  197,  200 

in  mucous  colitis,  207 

in  nephritis,  348 

in  tetany,  366 

in  urticaria,  408 

malted.     See  Malted  milk. 

market,  188 

standards  of,  102 
unsafe  in  summer,  188 

maximum    amount    of,    after     first 
year,  145 

raw,  in  constipation,  169 

resuming,  after  diarrhea,  161,  196 

selected,  188 

stopping,   in  acute    intestinal    infec- 
tion, 197 

supply  in  country,  492 

to  be  avoided  in  tvphoid  fever,  457 
Milking,  directions  for,  189 
Minced  beef,  when  allowed,  130 
Mineral  substances  in  foods,  function 

of,  60 
Mixed  feeding,  70 

in  wet-nursed  babies,  74 

infections  of  throat,  237 

treatment,  392 
Modern  school  system,  pernicious,  58 
Modified  milk,  definition  of,  81 
Moist  air  in  care  of  measles,  332 

skin  predisposing  to  colds,  228 
Molar  teeth,  time  of  appearance  of,  35 
Molasses  and  water  injection  for  fecal 

impaction,  260 
Mongolian  idiot,  385 
Morphin  in  acute  gastro-intestinal  in- 
fection, 192 

in  convulsions,  364 

in  cyclic  vomiting,  472 

in  meningitis,  375 

in  pronounced  vomiting,  1 79 

unnecessary  in  asthma,  265 

with  atropine,  ratio  of  doses,  179 
Mortality  from  summer  diseases,  160 

statistics  valueless  in  regard  to  nu- 
tritional errors,  80 
Mosher's  kindergarten  chair,  510 
Mother,  education  of,  17,  21,  161 

ignorance  of,  due  to  physician,  43 

nursing.     See  \ursing  mother. 
Mountains,  492 

Mouth  breathing  due  to  adenoids,  426 
to  hypertrophied  tonsils,  239 

portal  of  entry  of  pyogenic  bacteria, 
49 

temperature  in  children,  475 

toilet,  221,  222 


Mucous  colitis,  206 
diet  in,  206 
stools  in,  206 
Multiple  neuritis  due  to  arsenic,  381 
to  exanthemata,  381 
to  lead,  381 
to  malaria,  381 
to  phosphorus,  381 
Mumps,  334 

complicated  with  nephritis,  334 
a  rare  cause  of  deafness,  422 
with  orchitis,  355 
Muscular  twitchings  in  acute  intestinal 

infection,  199 
Musk  as  a  heart  stimulant,  277 
Mustard  as  a  counterirritant,  493 
baths,  30,  260,  268,  269,  363 
leaves,  178 

plasters,  259,  265,  269,  280 
Mutton  broth,   formula  for  preparing, 

123 
Myocarditis,  294 

after  diphtheria,  379 
endocarditis,  293 
pneumonia,  293 
scarlet  fever,  293 
diet  in,  294 
rest  in,  295 
sitting  up  after,  295 
stimulation  in,  294 
Myxedema,  infantile,  445 


Napkin  washer,  20 

Nasal  discharge,  chronic,  due  to  ade- 
noids, 426 
hemorrhage  due  to  adenoids,  234 
to  ulcerations  of  nasal  septum, 
234 
treatment  of,  234 
Nasopharynx,      inflammation     of,     as 

cause  of  asthma,  263 
Negro,  rickets  in,  441 
Nephritis,  acute,  bathing  in,  344 
bowel  function  in,  344 
colon  flushing  in,  346 
diet  in,  344 
hot  packs  in,  346 
treatment  of,  343-345 
urea  in,  347 

uremic  convulsions  in,  347 
chronic  diffuse,  348 
baths  in,  348 
beef  foods  in,  129 
climate  in,  349 
clothing  in,  349 
diet  in,'  348 
exercise  in,  349 
headache  in,  359 
in  mumps,  334 
interstitial,  349 

maternal     nursing     contraindi- 
cated  by,  71 


586 


Nephritis,  chronic  diffuse,  rare    under 
three  years,  348 
secondary  to  acute,  348 
vomiting  caused  by,  176 
post-scarlatinal,  321 
Nerve  grafting,  387 
Nervous  cough,  255 

disorders  of  childhood,  162 
Nettle-rash,  407 

Neurasthenia  diminishing  among  wo- 
men, 62 
Neuritis,  multiple,  381 
Neurotic  eczema,  404 
New  Mexico  for  tuberculosis,  501 
New    York    County    Medical    Society, 

Milk  Commission  of,  103 
Newly  born,  affections  of,  45-55 
asphyxia  of,  48 
atelectasis  of,  51 
cephalhematoma  of,  50 
granuloma  of,  53 
hemorrhagic  diseases,  53 
jaundice  in,  50 
mastitis  in,  52 
sepsis  in,  49 
tetanus  of,  54 
time  for  first  bath  in,  29 
umbihcal  polyp  of,  "51 
Night  bottle,  88 

breaking  from,  88 
terrors,  365 

watch  in  masturbation,  436 
Nipple,  care  of,  23,  72 
cracked  and  fissured,  77 
depressed,  79 

shield  in  cracked  nipples,  78,  79 
Nitrate  of  potash  in  asthma  of   older 

children,  265 
Nitre,    sweet    spirits   of,    in    cough    of 

measles,  332 
Nitric  acid  in  noma,  225 

in  pertussis,  325 
Nitrogenous  food  in  acid  urine,  338 
Nitroglycerin  contraindicated  in  myo- 
carditis, 295 
in  cyanosis,  271,  276 
Nitrous  oxid   gas  and    ether    in    ade- 
noids, 428 
danger    signals    in    administra- 
tion, 495 
under  two  years  to  be  used  with 

caution,  495 
with  caution,  495 
Noma,  224 

Nose,  portal  of  entry  of  pyogenic  bac- 
teria, 49 
Nursery,  airing  of,  24 
changing  napkins  in,  24 
floor  of,  24 
fresh  air  in,  25 
maid,  gonorrhea  in,  23 
physical  examination,  23 
schools  for  training,  23 


Nursery  maid,  tuberculosis  in,  23 
requirements  of,  24,  25 
shades  for,  25 
steam  heat  in,  25 
sweeping  in,  24 
temperature  of,  147 
ventilation  of,  24 
Nursing.     See  Klaternal  nursing. 
bottle,  care  of,  23 

mother,   amount   of  food   necessarv 
for,  65 
constipation  in,  a  cause  of  colic  in 

child,  165 
diet  of,  64 
mid-day  rest  for,  66 
rules  for,  64 
requirements  of,  23 
Nutrient  enema,  115,  141 
in  cyclic  vomiting,  472 
in  persistent  hematemesis,   185 
in  post-diphtheritic  paralysis,  381 
suppositories,  138 
Nutrition  a  factor  in  treatment  of  tub- 
erculosis, 285 
and  growth,  55-155 
defective,  a  cause  of  many  deaths,  80 
important  in  tuberculous  peritonitis, 
469 
Nutritional  disorders  of  childhood,  in- 
digestion a  factor  in,  162 
Nux  vomica,  tincture  of,  66,  126,  437, 
441,  458 
in  constipation,  164,   174 
in    malnutrition     of     syphilitic 

origin,  393 
in  mucous  colitis,  207 
in  tardy  malnutrition,  159 
in  tuberculosis,  287 
Nystagmus  associated  with  gyrospasm, 
366 


Oatmeal,  145 

a  cause  of  urticaria,  407 

gruel  in  the  cure  of  constipation,  171 

when  allowed,  130 
jelly,  129 

formula  for  preparing,  123 
water,  formula  for  preparing,  124 

in  constipation  of  bottle  fed,  169 
when  allowed  as  a  cereal,  130 
Obesity,  diet  in,  438 
Obstetrical  paralysis,  386 
O'Dwyer,   Joseph,   M.   D.,   inventor  of 

intubation,  310 
Oil  injections  in  constipation  of  bottle 
fed,  70 
in  malnutrition  of  infants,  158 
in  prolapse  of  rectum,  217 
inunctions  in  chronic  ileocolitis,  206 
in  marasmus,  156 
in  measles,  331 
in  scarlet  fever,  317 


587 


Oil  of  cade  in   collodion,  402 

of  wintergreen  in  rheumatism,  467 
treatment  for  constipation,  159,  164, 
168,  174,  262,  372 
Oiled  silk  jacket,  267,  274 
Ointments  in  cracked  nijjplcs,  78 

in  eczema,  403 
Oleoresin  of  male  fern  in  tai)c-worm, 

216 
Oleum  phosphoratum  in  rickets,  444 
Olive  oil  in  constipation,  170 

in  contagious   impetigo,  408 
in  mucous  colitis,  206 
in  seborrhea  capitis,  406 
rub,  139,  146 
Omelet,  when  allowed,  131 
Open    windows    a    cause    of    catching 

cold,  229 
Operation  for  appendicitis,  211 
for  bow-legs,  444 
for  cleft-palate,  398 
for  hare-lip,  time  of,  398 
for  pyloric  stenosis,  186 
for  rectal  prolapse,  217 
for  spina  bifida,  397 
for  tuberculous  adenitis,  430 
for  umbilical  hernia,  396 
Opium  and  its  derivatives  in  diabetes, 
357 
contraindicated  in  colic    166 
in  diarrhea,  193 

of  typhoid,  458 
in  gastric  indigestion,  1 79 
in  hysteria,  362 
in  ileocolitis,  201 
narcosis,  gavage  in,  137 
Optical  delusions  in  intestinal  toxemia, 

163 
Orange  juice  in  constipation  of  bottle- 
fed,  170 
in  scurvy,  445 
Oranges,  when  allowed,  131 
Orbicularis   oris,    hypertrophy   due   to 

thumb-sucking,  432 
Orchitis     complicating     nmmps,     334, 

355 
Otitis  media,  418 

a  cause  of  facial  paralysis,  383 
of  obscure  elevation  of  temper- 
ature, 479 
of  persistent  deafness,  422 
danger    of,    from     throat     irriga- 
tions, 309 
in  influenza,  453 
in  measles,  332 
in  scarlet  fever,  319 
suppurative,  422 
Outdoor  exercise  after  pleurisy,  280 
Outdoors,  going  out,  37,  147 
Overeating  as  cause   of   dilatation   of 
stomach,  183 
of  vomiting,  176 
during  second  year,  128 


Overeating,  effect  of,  on  milk,  69,  127 

in  nurslings,  69 
Overwork  in  exercises,  57 
Oxygen  in  atelectasis,  52 

in  pneumonia,  272 
Oxyuris  vermicuiaris,  215 


Pacitier,  432 

Packs.     vSee  Cool  pack. 

Pad  for  umbiHcal  hernia,  396 

Pain  a  symptom  of  pleurisy,  278 

counterirritants  for,  493 

in  chest,  often  absent  in  lobar  pneu- 
monia, 273 

in  otitis,  419 

in  peritonitis,  469 
Pancreas,    starch -converting     enzyme 

of,  122 
Paper  napkin  for  tuberculosis  sputum, 

287 
Paracentesis    of    membrana     tympani 
in  ciironic  otitis  media,  422 
indication  for,  420 
Paralysis,  Erb's  obstetrical,  386 

infantile,  378 

of  larynx  after  diphtheria,  379 

of  pharynx  after  diphtheria,  379 
Paraphimosis,  treatment  of,  354 
Paraplegia,  384 
Parasiticide  for  ringworm  of  the  scalp, 

415 
Paregoric,  201,  289,  332 
Park,     Dr.    William    Hallock,    experi- 
ment in  summer  diarrhea,  189 
Parotitis,    epidemic,    334.       See    also 

Mumps. 
Parsons  on  bacteria  and  cow's  milk,  99 
Pasteurization  of  milk,  1 1 1 
Patent  medicines,  502 
Patient,  first  examination  of,  39 
Pavor   diurnum    of    intestinal   origin, 

162 
Peaches,  when  allowed,  132 
Pears,  when  allowed,  131 
Peas,  when  allowed,  131,  145 
Pediculi,  treatment  of,  413,  414 
Peliosis  rheumatica,  468 
Pemphigus  due  to  syphilis,  469 

neonatorum,  408 
Peppermint  water  as  a  vehicle,  504 
Pepsin,  essence  of,  for  making  junket, 
125 
whey,  125 

in  stomach  of  young  child,  61 
Peptonized  milk,  115 
in  adaptation,  97 
in  diflficult  feeding,  108 
in  gavage,  137 
in  rectal  feeding,  140 
in  tetany,  367 
processes,  1 1 5 
Peptonizing  tubes,  116 


588 


INDEX 


Percentage  composition  of  foods,  60 
Perforating  ulcer  of  stomach,  rarity  of, 

184 
Pericarditis  as  cause  of  pleurisy,  279 
due  to  rheumatism,  289 
rheumatic,  treatment  of,  290 
Pericardium,  incision  of,  290 
Pericranial  hemorrhage  in  newly  born, 

54 
Perimastoiditis  as  sign  of  mastoiditis, 

423 
Periodic  temperature  in  empyema,  454 
in  fatigue,  454 
in  influenza,  454 
in  intestinal  infection,  454 
in  malaria,  454 

not  due  to  malaria,  but  cured  by 
quinin,  479 
Periostitis  of  tibia,  syphilitic,  391 
Peristalsis,  visible,  in  tuberculous  peri- 
tonitis, 469 
Peritonitis,  acute  general,  469 

infective,    causing    intestinal    ob- 
struction, 210 
tuberculous,  469 

causing  intestinal  obstruction,  209 
fever  in,  470 
rest  in  bed  in,  470 
Peritonsillar  abscess,  240 

irrigation  of  the  throat  in,  245 
peptonized  milk  by  gavage  in,  115 
Permanent  teeth,  order  of  their  appear- 
ance, 35 
Permanganate    of    potash    in    gonor- 
rhea, 355 
Peroxid  of  hydrogen  in  noma,  225 
Persistent   adenitis,    often   tubercular, 
425 
operation  on,  425 
cough  after  intubation,  313 
due  to  adenoids,  255 
to  adherent  pleura,  244 
vomiting  diagnosed  as  gastritis,  177 
due  to  congenital  pyloric  stenosis, 

186 
in  acute  gastric  indigestion,  177 
Pertussis,  321 

age  of  occurrence,  322 
antipyrin  and  bromid  in,  328 
belt  for,  328 

bronchopneumonia  in.  323 
catarrhal  stage,  327 
causing  hernia,  375 

vomiting,  176 
complications  of,  323 
convulsions  in,  323 
diagnosis  of,  early,  323 
extravasations  of  blood  in,  324 
fresh  air  in,  328 
greatest  susceptibility  to,  328 
incubation  period  of,  322 
malnutrition  in,  323 
management  of,  324 


Pertussis,  percentage  of  susceptibility 
to,  323 
quinin  in,  325 
season  of  occurrence,  322 
steam  inhalations  in,  323 
transitory  deafness  in,  323 
tuberculosis  in,  323 
versus  laryngismus  stridulus,  252 
without  a  whoop,  323 
Pharyngitis,  236 
Pharynx,     post-diphtheritic     paralysis 

of,  379 
Phenacetin,  477 

in  bronchopneumonia,  270 
in  influenza,  452 
in  typhoid  fever,  459 
Phimosis,  353 

as  cause  of  convulsions,  353 
causing  difficult  micturition,  336 
incontinence  of  urine,  338 
retention,  337 
deterrent  to  growth,  143 
in  epileptics,  372 
in  masturbation,  433 
treatment  of,  381 
Phosphorus  as  cause  of  multiple  neu- 
ritis, 381 
Physical    examination,   frequency    of, 

in  measles,  332 
Pin-worms,  215 
Plasmodium  malaria^,  454 
Plaster-of-Paris,  444 
Play  in  chorea,  368 
Pleura,   adherent,   as  cause  of  cough, 

255,  256 
Pleurisy,  acute  primary  non-rheumatic, 
278 
dry,  278 

iodin  in,  494 
secondary,  279 
tubercular,  primary,  280 
with  effusion  of  rheumatic  origin,  466 
of  tuberculous  origin,  280 
Pleuritic  adhesions,  280 
effusions,  279 

pain,  counterirritation  in,  493 
Pneumonia,  broncho-,  266-272 
bowel  function  in,  68 
complicating  influenza,  453 
measles,  330 
pertussis,  323 
diet  in,  267 
drugs  in,  269 
fever  in,  258 
hydrotherapy,  271 
hygiene,  267 
inhalations,  268 
oxygen  in,  272 
central,  273 
lobar,  272-278 
alcohol  in,  498 
as  cause  of  endocarditis,  296 
of  pleurisy,  279 


INDEX 


589 


Pneumonia,      lobar,     complicated     by 
multiple  neuritis,  381 
convulsions  in  onset  of,  363 
crisis  in,  273 
delayed  signs  of,  273 
hcaciaches  in  onset  of,  359 
onset  of,  272 
physical  signs  of,  273 
treatment  of,  278 
Podophyllin  in  cure  of  constipation,  1 74 
Poisoning  from  impure  bismuth,  194 

from  rhus  toxicodendron,  410 
Poliomyelitis,  acute  anterior,  378 
drugs  in,  379 
electricity  in,  379 
massage  in,  379 
prevention  of  deformity,  379 
treatment  in  acute  stage,  378 
Polyuria,  absence  of,  in  glycosuria,  329, 

350 
Position  for  defecation  in  rectal  pro- 
lapse, 217 
Post-cervical  glands,  enlarged,  in  Ger- 
man measles,  333 
Post-diphtheritic  paralysis,  379-381 
age  of  occurrence,  378 
difficult  swallowing  in,  379 
gavage  in,  381 
heart  action  in,  379 
irregularity  of  pulse  in,  378 
of  extremities,  379 
of  larynx,  379 
of  pharynx,  379 
rectal  feeding  in,  381 
treatment  of,  379-381 
Postural  treatment  of  rectal  prolapse, 

217 
Posture  and  breathing,  508 
Potassium  chlorate  in  tonsillitis,  239 
citrate,  352 

in  acute  pyelitis,  352 
in  eczema  due  to  hyperacidity,  401 
iodid,    391,   392.     See  also   lodid  of 
potash. 
Potato,  baked,  when  allowed,  130 

stewed,  when  allowed,  131 
Pott's   disease,  secondary  to   tubercu- 
lous peritonitis,  470 
Poultice,  flaxseed,  278 

flaxseed  and  mustard,  278 
Poultry,  when  allowed,  131 
Predigested  cereals  in  gavage,  137 
foods  during  illness,  133 
in  lobar  pneumonia,  277 
Pregnancy  a  contraindication  to  lacta- 
tion, 71 
Premature  infants,  45-47 
air  for,  45 
cause  of  prematurity  and  effect  on 

hfe,  45 
feeding  of,  47 
length  of  life  in,  45 
warmth,  45,  46 


Prepuce,  adherent,  treatment  of,  352 
Prescriptions    for    laboratory    feeding, 
90 
of  exercise,  506 
Pressure  in  hemorrhagic  diseases  of  the 
newly  born,  54 
of  water  in  reduction  of  intussuscep- 
tion, 21 
Prevention    of    intestinal    diseases    of 

summer,  186 
Prickly  heat  in  overclad  children,  416 

starch  bath  in,  31 
Prolapse  of  rectum,  216 
operation  for,  2 1 7 
treatment  of,  217 
Proprietary  foods  as  cause  of  rickets, 
442 
of  scurvy,  445 
as  sole  diet,  57 

disadvantages   of   those   not   con- 
taining milk,  117 
dried  milk  foods,  1 18 
standard  for  selecting,  117 
Protection  against  colds,  149 
Proteid  content  of  intestine  as  cause 
of  intestinal  toxemia,  163 
of  cow's  milk,  98 

adaptation  of,  94-98 
modification  of,  82 
incapacity  as  cause  of  colic,  164 
indigestion,  signs  of,  89,  95 
minimum  for  normal  growth,  169 
in  proprietary  foods,  1 1 7 
Proteids,  essential  ingredients  of  foods, 
59 
functions  of,  60 
of  milk  as  cause  of  colic,  164 
where  found,  59 
Prunes,  stewed,  when  allowed,  130 
Pseudoleukemic  anemia  of  von  Jaksch, 

438 
Pseudomembrane  in  tonsillitis,  237 
Puddings,  when  allowed,  130 
Pulse,  irregularity  of,  after  diphtheria, 
379 
in  myocarditis,  294 
Purees    of    peas,    beans,   and    lentils, 

57 
Purpura,  causes  of,  449 
fulminant,  183 
in  peliosis  rheumatica,  468 
in  pyemia,  449 
in  septicemia,  450 
prognosis  in,  450 
Putrefactive  bacteria  and  cow's  milk, 

99 
Pyemic  infection  of  nose,  232 
Pyloric  spasm,  185 

stenosis,  congenital,  185 

as  cause  of  vomiting,  185 
operation  for,  185 
stomach  wave  in,  185 
treatment  of,  186 


590 


INDEX 


Quarantine,  300-302 

in  measles,  332 
Quassia,  infusion  of,  in  thread-worms, 

215 
Quiet  in  sick-room,  317 
Quincke  needle  for  lumbar  puncture, 

376 
Quinin  bisulphate,  504 

administration  of,  504 

by  hypodermic  injection,  455 
by  inunction,  455 
by  mouth,  455 
by  rectum,  455 
as  cause  of  urticaria,  407 
in  finger  sucking,  432' 
in  lobar  pneumonia,  278 
in  malaria,  455 

in  malnutrition  of  syphiHs,  393 
in  mucous  coHtis,  207 
in  neuritis,  382 
in  tuberculosis,  287 
in  typhoid  fever,  459 
Quinsy,    240.       See    Abscess,    periton- 
sillar. 


Rachitis,  441-445.     See  Rickets. 
Raspberry,   syrup  of,  as  vehicle,   222, 

326 
Raw  milk  vs.  sterilized  or  pasteurized 

milk,  112 
Records  of  cases,  39 

of  daily  illness,  blank  form  for,  61 
Rectal  bleeding  suggesting  polypus,  219 
feeding,  139-141 

after  acute  gastro-intestinal  indi- 
gestion, 178 
in  cyclic  vomiting,  472 
in  diphtheria,  310 
in  meningitis,  375 
of  peptonized  skimmed  milk,  115 
substances  contraindicated  in,  140 
irrigation  in  typhoid  fever,  460 
medication,  method  of  giving,  253 

sodium  salicylate  by,  290 
polypus,  219 

temperature  in  child,  475 
tube,  size  for,  208 
Rectum,  examination  of,  in  constipa- 
tion, 170 
prolapse  of,  216 
Recurrence  in  chorea,  370 
Recurrent  bronchitis,  261 
Red  meat  as  cause  of  rheumatic  at- 
tacks, 464 
in  asthma,  266 
in  cardiac  disease,  296 
in  habit  spasm,  370 
in  recurrent  bronchitis,  262 
to  increase  fat  in  milk,  167 
Reflex  eczema,  404 
Regurgitation,  persistent,  95 
Removal  from  home  in  chorea,  368 


Removal  of  adenoids  in  chronic  nasal 
discharge,  233 
in  mouth  breathing,  233 
in  nasal  hemorrhage,  234 
Rennet,  essence  of,  for  making  junket, 

125 
Resorcin  in  pertussis,  324 

in  seborrhea  capitis,  406 
Respirations  in  lobar  pneumonia,  273 
Rest  after  gymnastic  therapeutics,  507 
in  acute  endocarditis,  291 
in  anemia,  439 
in  chorea,  367 

in  diphtheritic  paralysis,  380 
Restlessness     in     broncho-pneumonia, 

270 
Results  in  pediatrics  often  delayed,  18 
Retention  of  urine,  336,  337 
Retropharyngeal  abscess,  242 
adenitis,  242,  429 

due  to  caries  of  cervical  vertebrae, 

245 
gavage  in,  115 
intubation  in,  310 
irrigation  of  throat  in,  245 
Revaccination,  485 
I    Rheumatic  diathesis,  239,  463 

in  hypertrophy  of  tonsils,  239 
family  history  in  cardiac  disease,  296 
pain,  chloroform  liniment  in,  494 
pleurisy,  279,  466 
Rheumatism  a  factor  in  asthma,  263 
in  chorea,  367 
j  in  cychc  vomiting,  472 

as  cause  of  endocarditis,  290 
of  erythema  nodosum,  401 
I  of  multiple  neuritis,  383 

j  of  recurrent  bronchitis,  464 

j        growing  pains  due  to,  463 
j        importance  of,  in  family  history,  39 
in  habit  spasm,  370 
joint  pains  due  to,  463 
management  of  case  of,  464 
occurrence  of,  463 
oil  inunctions  in,  138 
pleurisy  due  to,  466 
red  meat  in,  464 
sugar  in,  464 
tonsillitis  in,  463 
treatment  of,  local,  467 

between  attacks,  467 
underlying  recurrent  bronchitis,  262 
Rhinitis,    acute,    as   cause    of   chronic 
rhinitis,  272 
in  onset  of  measles,  230 
interferes  with  nursing,  229 
of  congenital  syphilis,  390 
versus  diphtheria,  nasal,  230 
rhinitis,  syphilitic,  230 
Rhubarb  and  calomel  in  pharyngitis, 
236 
and  soda  in  chronic  eczema,  404 
in  faucitis,  236 


INDEX 


591 


Rhubarb  and  soda  in  intestinal  indiges- 
tion, 164 
in  jaundice,  437 
Rhus  toxicodendron,   poisoning  from, 

410 
Rice  as  cereal,  when  allowed,    130 

water   after   gastro-intestinal   infec- 
tion, 192 
formula  for  making,  124 
Rickets,  441-445 

a  cause  of  laryngismus,  251 

and  infant  mortality,  441 

due  to  steriHzation  of  milk,  1 1 1 

in  gyrospasm,  366 

in  infantile  convulsions,  441 

in  laryngismus  stridulus,  251,  441 

kyphosis,  444 

predisposing  to  catching  colds,  229, 
441 
to  convulsions,  363 
Ringworm,  416 

of  scalp,  414,  415 
Roast  beef,  when  allowed,  131 
Rochelle  salts  in  caked  breasts,  71 
Roof  gardens,  147 
Rosary,  rachitic,  441 
Round-worms,  214 
Rubbing  through  teeth,  36 
Rubella,  333.     See  also  German  meas- 
les. 
Rules  for  care  of  infants  at  New  York 

Babies'  Hospital  Dispensary,  92,  489 


Saccharin  as  substitute  for  sugar  in 

rheumatism,  464 
in  cure  of  obesity,  438 
in  place  of  sugar  in  asthma,  266 
Salicylate  of  soda,  administration   of, 
503 
by  rectum,  290 

an  unpalatable  drug,  502 

dangers  of,  19 

dosage  of,  464 

in  antitoxin  urticaria,  307 

in  asthma,  266 

in  cardiac  disease,  296 

in  chorea,  368 

in  cyclic  vomiting,  473 

in  endocarditis,  291,  292 

in  erythema  multiforme,  410 

in  habit  spasm,  371 

in  influenza,  452 

in  meningitis,  375 

in  multiple  neuritis,  382 

in  pericarditis,  290 

in  pneumonia,  lobar,  278 

in  recurrent  bronchitis,  261  262 

in  urticaria,  408 

nausea  and  vomiting  from,  467 
Salicylic     acid     in     dusting     powder, 
53 

with  tar  locally  in  eczema,  405 


Saline  enema  in  sepsis  of  newly  born,  50 
solution,  normal,  in  cok)n  flushing, 
496 
Salivation  in  stomatitis,  220 
Salt  bath,  146 

during  illness,  483 
in  chroijic  ileocolitis,  206 
in  habit  spasm,  371 
water  fcjr  sponging,  480 
Sanitarium  treatment,  advantages  of,, 
501 
for  tuberculosis,  danger  of,  501 
Santonin  in  worms,  214,  215 
Sarsaparilla,  134 
Scabies,  412 
Scales  for  weighing,  33 
Scarification  in  erysipelas,  461 
vScarlatina,  314-321 

as  cause  of  endocarditis,  290 
of  general  peritonitis,  469 
of  otitis,  418 
clothing  during,  315 
compHcated  by  adenitis,  319 
by  arthritis,  321 
by  deafness,  320 
by  nephritis,  321 
by  neuritis,  multiple,  381 
by  otitis,  320 
convulsions  in  onset  of,  363 
death  rate  in,  314 
desquamation  in,  318 
diet  in,  315,  316 
fever  in,  317 

headache  in  onset  of,  359 
irrigation  of  throat  in,  245 
laxatives  in,  316 
management  of,  314 
serum  treatment  of,  317 
sick-room  in,  315 
urine  examination  in,  315 
with  myocarditis,  293 
Scarlatinal  nephritis,  348 
Scars  from  chicken-pox,  333 
School  children,  diet  suitable  for,  57 
for  delicate  children,  149 
hygiene,  512 
in  chorea,  368 
in  habit  spasm,  371 
in  malnutrition,  158 
Schultze's  method  for  artificial  respira- 
tion, 48 
Scoliosis,  521 

Scorbutus,  445.     See  also  Scurvy. 
Scraped  beef,  145 

formula  for  preparing,  123 
in  chronic  ileocohtis,  205 
in  typhoid  fever,  457 
when  allowed,  129 
Scurvy  due  to  proprietary  foods,  1 1 8 
to  sterilization  of  milk,  1 1 1 
orange-juice  in,  445 
Seashore,  147 

aggravating  catarrh,  492 


592 


INDEX 


Seashore  in  asthma,  501 

Season  as  factor  in  artificial  feeding,  93 

in  marasmus,  153 
Seborrhea  capitis,  405 

intertrigo,  406 
Seidlitz  powder,  291 
Separation  from  family  in  hysteria,  337 
Sepsis  in  newly  born  as  a  cause  of  hemor- 
rhagic disease,  54 
location  of  process,  49 
portal  of  entry  of,  49 
treatment  of,  49 
Serum  treatment  of  diphtheria,  302 

of  scarlet  fever,  316 
Shampoo  of  ohve  oil  and  kerosene,  415 
Sherry  wine,  126 

in  marasmus,  153 
in  tuberculosis,  287 
Showing  off,  pernicious,  362 
Sick-room,  43 

in  bronchopneumonia,  267 
in  grippe,  454 
in  lobar  pneumonia,  274 
in  measles,  331 
in  scarlatina,  315 
Silver  nitrate  in  cord-stump,  26 
in  cracked  nipples,  78 
in  fissure  of  anus,  214 

of  the  lips,  226 
in  granuloma,  53 
in  ulcer  of  frenum  of  tongue,  226 
Sitting,  posture  in,  508 

up,  time  for,  26 
Skimmed  milk  in  acute  intestinal  indi- 
gestion, 166 
in   convalescence  from  ileocolitis, 
203 
chronic,  205 
in  obesity,  438 

in  recovery  from  diarrhea,  194 
in  rectal  feeding,  141 
mixtures,  85 

pancreatized,  in  enemata,  140 
percentage  equivalents  of,  85 
Skin  as   portal  of  entry  for   pyogenic 
bacteria,  49 
care  of,  in  chicken-pox,  333 
diseases  of,  400-417 
irritant  lesions,  in  epilepsy,  372 
lesions  affecting  growth,  143 
Sleep,  amount  of,  necessary,  27 
disturbed,  causes  of,  28 
induced  by  mustard-baths,  30 
talking  in,    due    to    intestinal   toxe- 
mia, 163 
Sleeping  alone,  25 
late,  159 
posture  for,  509 

rooms  for  delicate  children,  147 
Sleeplessness  in  pertussis,  327 
Snuffles,  230 

•Soap,  kitchen,  for  ringworm  of  scalp, 
414 


Soapsuds  enema.     See  Enema. 
Soda  bath,  3 1 

in  eczema,  403 
in  prickly  heat,  416 
mint  in  colic,  166 
Sodium      biborate     in      angioneurotic 
edema,  388 
in  tonsillitis,  238 
bicarbonate  in  grippe,  452 
bromid.     See  Bromid  of  soda. 
carbonate,  solution  of,  for  diapers,  29 
citrate,  96,  108 

sulphate    in    acute  gastro-intestinal 
infection,  192,  197 
Soft-boiled  eggs  in  typhoid  fever,  457 
Soiled  napkins,  care  of,  25 
Sore  mouth,  221.     See  also  Stomatitis. 
Soups,  when  allowed,  131 
Spasm,  habit,  370 
Spasmus  nutans,  365 
Spina  bifida,  397 
Spinach,  when  first  allowed,  130 
Spinal  ataxia,  exercises  for,  527 
canal,  injection  of  drugs  into,  375 
douche,  146 

in  recurrent  bronchitis,  263 
Spirit  of  mindererus,  476 
Sphnts  after  anterior  poliomyelitis,  379 

in  dactylitis,  470 
Spoiling  a  sick  child,  317 
Sponge  bath  in  diphtheria,  310 
in  fever,  476 
in  lobar  pneumonia,  275 
in  measles,  331 
in  mumps,  334 
in  scarlet  fever,  481 
in  summer,  487 
never  to  be  used  on  a  baby,  29 
Sprays,  309 

of  alijolene  and  menthol  for  rhinitis, 
230 
Spring  water,  492 
Sprue,  223 
Square  head,  441 

St.  Vitus'  dance,  367.  See  also  Chorea. 
Standard  of  milk  for  infant  feeding,  103 
Staphylococcus    albus    in    pemphigus, 

409 
Starch,  addition  of,  to  food,  beginning, 
128 
bath,  31 

in  prickly  heat,  418 
digestion,  in  young  infants,  120,  121 
feeding,  121-123 

in  ileocolitis,  205 
and  opium  enema  in  ileocolitis,  203 
Starvation  treatment  of  vomiting,  178 
Status  lymphaticus,  449 
Steak,  when  allowed,  131 
Steam  inhalation,  258 
in  bronchitis,  258 
in  bronchopneumonia,  258,  268 
in  catarrhal  croup,  249 


595 


Steam  inhalation  in  pertussis,  ^25 
Sterilization  of  milk,  effect  of,  111 

in  feeding  dispensary  patients,  93, 

111 
methods  of,  1 1 1 
Sterilized  milk  as  cause  of  scurvy,  445 
Sternomastoid,  hematoma  of,  398 
Stertorous  breathing   in    retropharyn- 
geal abscess,  242 
Stock  gruels,  457 

prescriptions,  502 
Stomach  cough,  255 

development  of,  by  milk,  61 
feeding,  substitutes  for,  138 
in  chronic  gastro-enteritis,  184 
in  newly  born,  184 
inflammation  of,  as  cause  of  vomit- 
ing, 176 
ulcers  of,  causing  hematemesis,  183, 
184 
vomiting,  176 
washing,  180.     See  also  Lavage. 
wave  in  congenital  pyloric  stenosis, 
186 
Stomatitis,  220 
aphthous,  220 
catarrhal,  220 
improper  care  of  mouth  as  cause  of, 

220 
mycotic,  223 
treatment  of,  222 
ulcerative,  220 
Stone  in  bladder,  351 
Stools,  green,  as  signal  for  giving  castor 
oil,  160 
due  to  high  fat,  67 

to  indigestion,  95 
immediate  treatment  of,  189 
in  bronchopneumonia,  268 
in  congenital  stenosis  of  pylorus,  186 
in  difficult  feeding,  108,  109 
in  fissure  of  anus,  213 
in  ileocolitis,  200,  204 
in  intussusception,  211 
in  typhoid  fever,  458 
in  unsuccessful  maternal  nursing,  67 
Strapping  chest  in  pleurisy,  278 

for  ventral  hernia,  397 
Straus  laboratory  milk,  188 

milk  charity,  91 
Strawberries  as  cause  of  urticaria,  407 
Streptococcus  causing  purpura,  450 
throat,  cHnically  like  diphtheria,  303 
usually  cause  of  retropharyngeal  ab- 
scess, 242 
String-beans,  when  allowed,  130 
Stringed  screen  for  gymnastic  thera- 
peutics, 506 
Strophanthus,  tincture  of,  abuse  of,  299 
in  bronchopneumonia,  270 
in  cardiac  disease,  299 
in  diphtheria,  310 
in  endocarditis,  291 

38 


I   Strophanthus,   tincture,    in    gastro-in- 
i  testinal  infection,  191 

I  in  ileocohtis,  201,  202 

in  intestinal  infectif)n,  199 
in  lobar  pneumonia,  276 
in  myocarditis,  293 
in  nephritis,  347 
in  pericarditis,  289 
in  postdiphtheritic  neuritis,  380 
in  scarlet  fever,  318 
in  typhoid  fever,  460 
Striimpell  quoted,  368 
Strychnin,  administration  of,  504 
after  diphtheria,  380 
contraindicated   in   acute   intestinal 

infection,  199 
dosage  in  myocarditis,  293 
in  bronchopneumonia,  270 
in  diphtheria,  310 
in  enuresis,  342 
in  lobar  pneumonia,  276 
in  mucous  colitis,  207 
in  neuritis,  382 
in  scarlet  fever,  318 
in  typhoid  fever,  460 
Study,  amount  of,  for  neurotic  children, 

361 
Stupes,  turpentine,  in  colic,  494 
Styptics  in  hemorrhagic  diseases  of  the 

newly  born,  54 
Substitute     feeding,      89.       See     also 

Feeding,  artificial. 
Sudden  death  due  to  myocarditis,  294 

to  status  lymphaticus,  449 
Suffocation    from    foreign    bodies    in 

larynx,  254 
Sugar,  administration  of,  causing  glyco- 
suria, 349 
capacity,  low,  in  chronic  gastritis,  HP' 
content  of  cow's  milk,  98 
in  asthma,  264-266 
in  cardiac  disease,  296 
in  chorea,  368 
in  cyclic  vomiting,  493 
in  obesity,  438 
indigestion,  94 
signs  of  excess,  in  food,  95 
water,  between  nursings,  73 
Suggestion  a  factor  in  children's  com- 
plaints, 360 
Sulphid    of    calcium    in    furunculosis, 

412 
Sulphur  in  administration  of  bismuth, 
194,  201 
in  ringworm  of  scalp,  414 
ointment  in  scabies,  412 
Summer,  bathing  in,  489 

care  of  feeding  bottles  in,  490 

of  milk  in,  489 
clothing  in,  489 

diarrhea.     See  Indigestion,  acute  in- 
testinal. 
mortahty  in,  160 


594 


INDEX 


Summer,  fresh  air  in,  489 
instructions  for,  487 
resorts,  491,  492 

for  delicate  children,  148 
sleeping,  489 

undigested  stools  during,  487 
Suppositories,  168 

in  constipation,  170 
Suppression  of  urine,  337 
Suppuration  of  cephalhematoma,  50 

of  glands,  treatment  of,  425 
Suprarenal  extract  in  persistent  hemat- 
emesis,  185 
in  purpura,  450 
Suspensory  bandage  after  orchitis,  156 
Swallowing,  difficulty,  after  diphtheria, 
380 
due    to    retropharyngeal    abscess, 
242 
Sweating  for  control  of  fever,  476 
Syphilis  as   cause   of    cerebral   palsy, 
383 
of  fissures  at  angle  of  mouth,  226 
congenital,  389-391 

epitrochlear  glands  in,  390 
inunctions   of   mercuric   ointment 

in,  389 
iodid  of  potash  in,  392 
later  treatment  of  389-391 
rash  of,  390 
contraindicating    maternal    nursing, 

71 
hereditary  transmission  of,  431 
hoarseness  in,  390 

importance  of,  in  family  history,  39 
oil  inunctions  in,  138 
tardy  hereditary,  391,  392 

malnutrition  an  evidence  of,  392 
transmitted  by  kissing,  28 
with  hemorrhagic  diseases  of  newly 
bom,  54 
SyphiUtic  dactyhtis,  470 
periostitis  of  tibia,  391 
Syrups  for  children,  269 
upsetting  indigestion,  19 


Table,  adjustable,  for  children,  509 
of  weights  and  heights,  32 

Taenia,  215 

Taking  cold,  228 

Tannalbin  in  ileocolitis,  202 

Tannic  acid  for  blood  in  stools,  208 
for  hemorrhoids,  218 

Tape  for  restraint  in  masturbation,  436 

Tape -worm,  216 

Tar  and  salicylic  acid  in  chronic  eczema, 
405 
ointment  of,  in  eczema,  403 

Tardy  malnutrition,  regimen  to  be  fol- 
lowed, 159 

Tartar  emetic,  administration,  503 
in  acute  catarrhal  laryngitis,  249 


Tartar  emetic  in  bronchitis,  260 
in  bronchopneumonia,  269 
in  faucitis,  236 
unpalatable,  503 
Tastes,  129 
Tasting,  132 
Taylor,  Dr.  A.  S.,  operations  for  cure  of 

hydrocephalus,  377 
Tea  after  sixth  year,  132 

constipating  for  nursing  mothers,  66 
drinking  as  cause  of  constipation,  167 
in  typhoid  fever,  457 
Teeth,  care  of,  35 
cavities  in,  35 
first  tooth  to  appear,  35 
in  rickets,  441 
loss  of  first,  35 

presence  of,  necessary  for  ulcerative 
stomatitis,  220 
Teething  cough,  225 
Temperature,  abnormal  rise  of,  475 
birth,  474 

by  what  to  reduce,  270,  271 
effect  of  antitoxin  on,  in  diphtheria, 

304 
in  earache,  418 

in  gastro-intestinal  infection    190 
in  influenza,  452 
in  lobar  pneumonia,  273 
in  marasmus,  152 
normal,  474 
obscure  elevations  of,  477-479 

caused   by  encysted  empyema, 
479 
by  exercise,  477 
by  intestinal  infection,  479 
by  otitis,  479 
by  tuberculosis,  479 
by  typhoid  fever,  479 
of  dressing-room,  229 
of  sick-room,  267,  274 
periodic,  in  malaria,  454 
reduction  of,  when  to  reduce,  271 
subnormal,  by  axilla,  475 
by  mouth,  475 
by  rectum,  475 
in  cretins,  446 
in  measles,  332 
unexplained,  480 
when  to  interfere  with,  476 
Tendon-transplantation     after     polio- 

myeUtis,  379 
Tenesmus,  202 

Tenotomy  after  poliomyehtis,  379 
I    Tetanus  antitoxin,  54 
neonatorum,  54 
Tetany,  366 

Therapeutic  nihihsm,  18 
Thermometers  in  nursery,  25 
Thickened  lips  due  to  use  of  pacifier,  432 
Thirst,  absence  of,  in  glycosuria,  349 
:   Thoracotomy  for  double  empyema,  284 
1        in  empyema,  282 


INDEX 


595 


Thread-worm,  215 

and  masturbation,  433 
as  cause  of  enuresis,  378 
in  night-terrors,  365 
Throat,  examination  of,  234 
Thrush,  223 
Thumb  sucking,  432 

results  of,  432 
Thymic  asthma,  449 
Thymus,    enlarged,    and    convulsions, 

365 
Thyroid  extract,  dosage,  448 
evidences  of  excess  of,  447 
in  cretinism,  447 
in  obesity,  438 
Tinea  circinata,  416 

tonsurans,  414 
Tomatoes  as  cause  of  urticaria,  407 

stewed,  when  allowed,  130 
Tongue,  bridle,  226 

swelling  of,  in  angioneurotic  edema, 

387 
traction    on,    Laborde's    method    of 

artificial  respiration,  48 
ulcer  of  frenum  of,  226 
Tongue-tie,  treatment  of,  227 
Tonsillar  punch  for  hvpertrophied  ton- 
sils, 240 
Tonsillitis  associated  with  cardiac  dis- 
ease, 292,  296 
with  rheumatism,  463 
diagnosis  versus  diphtheria,  237 
difficulty  in  swallowing  in,  238 
duration  of,  237 
onset  of,  236 
preceding  otitis,  468 

quinsy,  240 
sprays  in,  238 
symptoms  of,  237 
treatment  of,  237-239 
Tonsils,  a  cause  of  persistent  deafness, 
422 
a  harboring  place  for  bacteria,  239 
hypertrophied,  239  • 

in  epileptics,  372 
in  night-terrors,  365 
removal  of,   for  chronic  bronchitis, 

261 
with  asthma,  263 
Tooth  picks,  35 

powder,  35 
Top-milk   in    cure    of   constipation    of 

older  children,  1 7 1 
Toxemia,  intestinal,  diagnosed  as  mala- 
ria, 162 
as  worms,  162 
due  to  defective  bowel  evacuation, 
167 
Trachea,  cast  of,  314 
Tracheitis  as  cause  of  persistent  cough, 

255 
Tracheotomy    for    foreign    bodies    in 
larynx,  254 


Trauma  as  cause  of  cerebral  palsy,  383 

of  early  convulsions,  363 
Traumatic  laryngitis,  253 
Trichophyton,  416 
Truss,  cleaning,  395 
in  inguinal  hernia,  395 
in  umbilical  hernia,  396 
in  undescended  testicle,  356 
measuring  for,  395 
Tub  baths  for  fever,  318,  476 
Tubercle  bacilli  in  sputum  of  children, 

285 
Tuberculosis  as  cause  of  obscure  eleva- 
tion of  temperature,  479 
cHmate  in,  285 
contraindicating    maternal    nursing, 

71 
devices  for  collecting  sputum  in,  287 
fatality  in  young  children,  285 
frequency  of  occurrence,  285 
fresh  air  in,  286 
high  proteid  diet  in,  285 
home  treatment  versus  sanitarium, 

286 
importance  of,  in  family  history,  39 
in  bronchiectasis,  288 
in  delicate  child,  143 
infiltration  of,  incipient,  a  cause  of 

persistent  cough,  256 
in  marantic  cases,  152 
in  nursery  maids,  23 
in  pertussis,  323 
occurrence  of,  286 
of  cervical  lymph-glands,  430 
of  hip-joint,  471 
of  knee-joint,  471 
of  spine,  471 
oil  inunctions  in,  138 
physical  signs  of,  285 
prognosis  in,  287 
tenement  cases,  287 
transmitted  by  kissing,  28 
Tuberculous  dactylitis,  470 
peritonitis,  469 
suppurative,  469 
Tumors  of  intestine  causing  intestinal 

obstruction,  210 
Turbinate  bones  causing  nasal  catarrh, 

232 
Turpentine  as  counterirritant,  493 
in  bronchoi:)neumonia,  268 
in  thread-worms,  214 
inhalations  in  pertussis,  325 
Tympanites,  458 
Typhoid  fever,  alcohol  in,  498 
antipyretic  drugs  in,  460 
care  of  mouth  in,  456 
cervical  adenitis  in,  457 
diarrhea  in,  459 
diet  in,  457,  458 
disinfection  of  excreta  in,  457 
gingivitis  in,  457 
heart  stimulants  in,  460 


596 


INDEX 


Typhoid  fever,  hemorrhage  in,  461 
hydrotherapy  in,  460 
intestinal  antiseptics  in,  458 
milk  in,  457 
perforation  in,  461 
rarity  of,  in  children,  456 
rectal  irrigations  in,  460 
stools  in,  458 
treatment  of,  456-461 
tympanites  in,  458 
Widal  reaction  in,  456 


Ulceration  at  corner  of  mouth,  226 
of  hard  palate,  225 
of   nasal    septum   a   cause   of   nasal 

hemorrhage,  224 
of  stomach,  184 
Ulcerative  stomatitis  in  typhoid  fever, 

457 
Umbilical  cord,  care  of  stump,  26 
hypertrophy  of  stump,  53 
suppuration  of  stump,  26 
hernia,  396 

strapping  for  cure  of,  396 
polyp,  51 

treatment  of,  5 1 
Umbilicus  as  portal  of  entry  for  infec- 
tion, 49 
Undescended  testicle,  356 
Unguentum  hvdrargyrum  in  congeni- 
tal syphilis,  388 
Urea  excretion,  normal,  and  in  nephri- 
tis, 347 
Uremia,  convulsions  in,  363 

in  acute  nephritis,  346,  349 
Urethra  as  portal  of  entry  for  pyogenic 
bacteria,  49 
calculi  of,  causing  difficult  micturi- 
tion, 336 
injury  to,  a  cause  of  retention,  337 
Urethritis,  specific,  355 
Urination,  difficult  and  painful,  336 
frequent,  a  precursor  of  bed-wetting, 
335 
Urine,  335 

acidity  of,  amount    and   frequency, 
factors  influencing  them,  335 
as  cause  of  difficult  urination,  336 
enuresis,  338 
per  day,  335 
continence  of,  336 
devices  for  collecting,  336 
examination  at  bedside,  315 

in  measles,  331 
in  jaundice,  437 
in  nephritis,  348 
in  scarlatina,  345 
incontinence  of,  336,  338 
specific  gravity  of,  335 
Urotropin  in  acute  pyehtis,  352 

in  cystitis,  352 
Urticaria,  407 


Urticaria  due  to  external  irritation,  407 
to  internal  causes,  407 
following  antitoxin,  307 
giant,  387 
low  diet  in,  408 
treatment  of,  408 

Uvula,  elongation  of,  ascause  of  persis- 
tent cough,  285 


Vaccination,  age  for,  484 
complications  of,  485 
methods,  484 
shield  for,  485 
virus  for,    484 
Vagina,   portal  of  entry  for  pyogenic 

organisms,  49 
Vaginal  discharge  a  deterrent  to  growth, 
143 
in  nursery  maids,  23 
Vaginitis  as  cause  of  incontinence  of 
urine,  338 
of  retention  of  urine,  337 
Valentine's  beef-juice,  119 
Vapo-cresoHne  inhalations  in  pertussis, 

325 
Vaporizations  in  diphtheria,  309 
Varicella,  332 

care  of  skin  in,  333 
Ventral  hernia,  397 
Vesical  calculus,  351 
Vichy,  134 

Visitors  in  sick-room,  274 
Visual  defects  in  epilepsy,  372 
A'oice  in  retropharyngeal  abscess,  242 
Vomiting,  176 

after  adenoids,  429 

causes  for,  176 

cyclic,  473 

due  to  fat  indigestion,  95 

to  too  strong  food,  88 
during  nursing,  67 
g^vage  in,  135,  136 
in  congenital    stenosis    of    pylorus, 

185,  186 
in  acute  gastric  indigestion,  178 

gastro-intestinal  infection,  192 
in  chronic  gastritis,  179 
in  dilatation  of  the  stomach,  183 
in  pertussis,  belt  for,  328 
lavage  in,  180 
of  blood,  183 

persistent,  a  sign  of  peritonitis,  469 
in  congenital  stenosis  of  pylorus, 
185,  186 
projectile,  in   congenital  stenosis  of 
pylorus,  185 
with  sprue,  223 
Von   Jaksch,    pseudoleukemic   anemia 

of,  438 
Vulvar  douching,  357 
Vulvovaginitis,  gonorrheal,  357,  358 
simple,  357 


597 


Waking,  time  for,  25 

Walker-Gordon    Laboratory    milk    for 

traveling,  116 
Walking  movements,  513 
Warm  air  in  asthma,  265 
in  meningitis,  374 
pack  in  meningitis,  374 
Washing  child's  mouth,  221,  222 
in  eczema,  403 
mouth  in  sprue,  204 
Water  before  nursing  in  fever,  133 
function  of,  as  a  constituent  of  food, 

60 
in  maternal  nursing,  73 
in  morning,  184 
fti  nephritis,  343,  345 
pressure  of,  in  reduction  of  intussus- 
ception, 21 1 
Water-bed  in  decubitus,  413 
Weaning,  71,  128 
Weighing  infants,  144 

during  nursing,  68,  75,  152 
frequency,  31 
Weight  at  birth,  31 
chart,  32 
initial  loss  of,  31 
loss  of,  in  the  mother,  contraindicat- 

ing  nursing,  7 1 
normal  amount  of  gain  in,  32 
of  girls  compared  to  boys,  32 
stationary,   a    premonitory   sign    of 
malnutrition,  144 
in  maternal  nursing,  67 
Well-water  in  country,  492 
Wet  compresses  for  laryngitis,  254 
dressings  of  bichloride,  49 

of  boric  acid,  49 
sweeping  in  measles,  332 
Wet-nurse    after    gastro-intestinal    in- 
fection, 195 
age  of,  73 
diet  of,  65 
examination  of,  74 
in  anemia  of  the  bottle-fed,  439 
in  difficult  feeding  cases,  108 
in  gastritis,  chronic,  179 


Wet-nurse  in  marasmus,  151 

in  premature  infants,  47 

in  stenosis  of  the  pylorus,  1 86 

in  tetany,  367 

selection  of,  74 
Wlieat  crackers  as  cause  of  constipa- 
tion, 171 

jelly,  formula  for  preparing,  123 
Wheatena,  when  allowed,  131 
Whey,  155 

formula  for  preparing,  125 

in  dinicult  feeding,  108 

in  premature  infants,  47 

mixtures,  96 
Whisky,  277.     vSee  also  Alcohol. 

in  erysipelas,  462 
White  l)read  as  cause  of  constipation, 
171 

precipitate  ointment  in  ringworm  of 
scalp,  414 
Whooping-cough.     See  also  Pertussis. 
Widal  reaction,  456 
Window-board,  25,  43,  57,  147,  258,  267, 

274 
Wine  after  second  year,  132 
Winter  diarrhea  predisposing  to  sum- 
mer diarrhea,  160,  187 
Woolen  clothing  after  nephritis,  347 
Worms  as  cause  of  convulsions,  363 

as  sign  of  intestinal  toxemia,  162 

symptoms  of,  214 

treatment  of,  216 
Worry,  bad  effect  on  lactation,  72 
Written  directions,  41 

Yerb.\  Sant.a,  a  menstruum  for  quin- 

in,  504 
Yerberizine,  a  vehicle  for  quinin,  326, 

504 

Zinc  oxid  in  eczema,  402,  403 
ointment  in  eczema,  405 
in  intertrigo,  404 
Zwieback,  457 

when  allowed,  129-132 


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"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  3 
rival." 


DISEASES   OE   WOMEN. 


HirstV 
Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with   701    original  illustrations,  many  in  colors. 

Cloth,  ^5.00  net;  Half  Morocco,  $^.^0  net. 

RECENTLY  ISSUED     NEW  (2d)  EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  v.ithout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  a  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  this  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior. to  the  descriptions  in 
many  other  text-  boks." 

Boston  Medical  and  Surgical  Journal 

"The  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

"Office  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS'    BOOKS   ON 


Penrose's 
Diseases  of  Women 

Fifth  Revised  Edition 


A  Text=Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with   225  fine  original  illustrations.     Cloth, 

$3.75   net. 

RECENTLY   ISSUED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted,  and  the  main  points  are  made  clear  by  excellent  illustra- 
tions. The  new  edition  has  been  carefully  revised,  much  new  matter  has  been 
added,  and  a  number  of  new  original  illustrations  have  been  introduced.  In  its 
revised  form  this  volume  continues  to  be  an  admirable  exposition  of  the  present 
status  of  gynecologic  practice. 


PERSONAL  AND   PRESS  OPINIONS 


Howard  A.  Kelly.  M.  D.. 

Professor  of  Gynecology  and  Obstetrics.  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women'  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 

E.  E.  Montgomery,  M.  D., 

Professor  of  Gynecology,  Jefferson  Medical  College,  Philadelphia. 
"  The  copy  of  '  A  Text-Book  of  Diseases  of  Women  '  by  Penrose,  received  to-day.     I  have 
looked  over  it  and  admire  it  very  much.     I  have  no  doubt  it  will  have  a  large  sale,  as  it  justly 
merits." 

Bristol  Medico-Chirurgical  Journal 

"  This  is  an  excellent  work  which  goes  straight  to  the  mark.  .  .  .  The  book  may  be  takea 
as  a  trustworthy  exposition  of  modern  gynecology." 


G  YNE  CO  LOG  1 '  A  ND    DBS  TE  TRIL  S. 


The  American 
Text-Book  of  Obstetrics* 

Second  Edition,  Thoroughly  Revised  and  Enlarged 


The  American  Text=Book  of  Obstetrics.  In  two  volumes.  Edited 
by  Richard  C.  Norris,  M.D.,  Assistant  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania;  Art  Editor,  Robert  L.  Dickinson,  M.D., 
Assistant  Obstetrician,  Long  Island  College  Hospital,  N.  Y.  Two 
handsome  octavo  volumes  of  about  6oo  pages  each;  nearly  900  illus- 
trations, including  49  colored  and  half-tone  plates.  Per  volume : 
Cloth,  ;^3.50  net ;  Sheep  or  Half  Morocco,  ^4.50  net. 

RECENTLY   ISSUED— IN   TWO  VOLUMES 

Since  the  appearance  of  the  first  edition  of  this  work  many  important  advances 
have  been  made  in  the  science  and  art  of  obstetrics.  The  results  of  bacteriologic 
and  of  chemicobiologic  research  as  applied  to  the  pathology  of  midwifery  ;  the  wider 
range  of  the  surgery  of  pregnancy,  labor,  and  of  the  puerperal  period,  embrace 
new  problems  in  obstetrics.  In  this  new  edition,  therefore,  a  thorough  and  critical 
revision  was  required,  some  of  the  chapters  being  entirely  rewritten,  and  others 
brought  up  to  date  by  careful  scrutiny.  A  number  of  new  illustrations  have  been 
added,  and  some  that  appeared  in  the  first  edition  have  been  replaced  by  others 
of  greater  excellence.  By  reason  of  these  extensive  additions  the  new  edition 
has  been  presented  in  two  volumes,  in  order  to  facilitate  ease  in  handling.  The 
pnce,  however,  remains  unchanged. 


PERSONAL  AND   PRESS  OPINIONS 


Alex.  J.  C.  Skene,  M.  D., 

Late  Professor  of  Gynecology,  Lovg  Island  College  Hospital,  Brooklyn. 
"  Permit  me  to  say  that  '  The  American  Text-Book  of  Obstetrics  '  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.     I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." 

Matthew  D.  Mann,  M.  D.. 

Professor  of  Obstetrics  and  Gynecology  in  the  University  of  Buffalo. 

"  I  like   it  exceedingly  and  have   recommended  the  first  volume  as  a  text-book  for  oui 
sophomore  class.     It  is  certainly  a  most  excellent  work.     I  know  of  none  better." 

American  Journal  of  the  Medical  Sciences 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi 
tioner,  we  commend  it  because  we  believe  there  is  no  better." 


SAUNDERS'    BOOKS    ON 


GET  ik     •  THE  NEW 

THE  BEST  /\  m  6  r  1  C  Si  n  standard 

Illustrated   Dictionary 

Just  Issued— New(4th) Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
DoRLAND,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  850  pages,  bound  in  full  flexible  leather. 
Price,  $^.SO  net;  with  thumb  index,  ^$5.00  net. 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 
Possible  Cost 

WITH   2000  NEW  TERMS 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  1 3^ 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  fifteen  hundred 
new  terms  that  have  appeared  in  recent  medical  literature  have  been  added,  thus 
bringing  the  book  absolutely  up  to  date.  The  book  contains  hundreds  of  terms 
not  to  be  found  in  any  other  dictionary,  over  100  original  tables,  and  many  hand- 
some illustrations,  a  number  in  colors. 


PERSONAL    OPINIONS 


Howard  A.  Kelly,  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Borland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
si»e.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.D.,  LL.D.,  F.R.C.S.  (Hon.) 

Professor  of  Surgery^  Harvard  Medical  School. 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.     It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.      I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AND    OBSTETRICS. 


Garrigues* 
Diseases  of  Women 

Third  Edition,  Thoroughly  Revised 


A  Text-Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues, 
A.  M.,  M.  D.,  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  New  York  City,  Handsome  octavo,  756  pages,  with  367 
engravings  and  colored  plates.  Cloth,  ^4.50  net;  Sheep  or  Half 
Morocco,  $6.00  net. 

The  first  two  editions  of  this  work  met  with  a  most  appreciative  reception  by 
the  medical  profession  both  in  this  country^  and  abroad.  In  this  edition  '.he  entire 
work  has  been  carefully  and  thoroughly  revised,  and  considerable  new  matter 
added,  bringing  the  work  precisely  down  to  date.  Many  new  illustrations  have  been 
introduced,  thus  greatly  increasing  the  value  of  the  book  both  as  a  text-book  and 
book  of  reference. 
Thad.  A.  Reamy.  M.  D. ,   Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

•One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning  and 
great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book. 


American 
Text-Book  of  Gynecology 

American    Text-Book   of     Gynecology:    Medical   and   Surgical. 
Edited  by  J.  M.  Baldy,  M.  D.,  Professor  of  Gynecology,  Philadelphia 
Polyclinic.     Imperial  octavo  of  718  pages,  with  341  text-illustrations 
and  38  plates.     Cloth,  s6.oo  net;  Half  Morocco,  $7.50  net. 
SECOND  REVISED  EDITION 

This  volume  is  thoroughly  practical  in  its  teachings,  and  is  intended  to  be  a 
working  text-book  for  physicians  and  students.     Many   of  the  most  important 
subjects  are  considered  from  an  entirely  new  standpoint,  and  are  grouped  together 
in  a  manner  somewhat  foreign  to  the  accepted  custom. 
Boston  Medical  and  Surgical  Journal 

■■The  most  complete  exponent  of  gynecology  which  we  have.     No  subject  seems  to  have 
been  neglected." 


SAUNDERS'    BOOKS   ON 


Dorland*s 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.     By  W.  A.  Newman 

Borland,  A.  M.,  M.  D.,  Assistant  Instructor  in  Obstetrics,  Univer- 
sity of  Pennsylvania;  Associate  in  Gynecology  in  the  Philadelphia 
Polyclinic.  Handsome  octavo  volume  of  797  pages,  with  201  illustra- 
tions.    Cloth,  $4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Amongthe  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortahty,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing( 

Obstetric  and  Gynecologic  Nursing.    By  Edward  P.  Davis,  A.  M., 

M.  D.,   Professor   of  Obstetrics    in   the   Jefferson  Medical   College  and 
Philadelphia   Polyclinic ;    Obstetrician    and    Gynecologist,   Philadelphia 
Hospital.      i2mo  of  400  pages,  illustrated.     Buckram,  $1.75   net. 
RECENTLY  ISSUED— SECOND  REVISED  EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  second  edition  has  been  very  carefully  revised  throughout,  bringing 
the  subject  down  to  date. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS.  13 


Schaffer  and  Edgar's 

Labor  and  Operative  Obstetrics 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medi- 
cal School,  New  York.  With  14  lithographic  plates  in  colors,  139  other 
illustration's,  and  in  pages  of  text.  Cloth,  ;^2.oo  net.  /;/  Saunders' 
Hand-Atlas  Series. 

This  book  presents  the  act  of  parturition  and  the  various  obstetric  operations 
in  a  series  of  easily  understood  illustrations,  accompanied  by  a  text  treating  the 
subject  from  a  practical  standpoint.  The  author  has  added  many  accurate  repre- 
sentations of  manipulations  and  conditions  never  before  clearly  illustrated. 

American  Medicine 

■•  The  method  of  presenting  obstetric  operations  is  admirable.  The  drawings,  representing 
original  work,  have  the  commendable  merit  of  illustrating  instead  of  confusing.  It  would  be 
d.fficult  to  find  one  hundred  pages  in  better  form  or  containing  more  practical  points  for 
students  or  practitioners."  ^^^^ 

Schaffer  and  Edgar's 

Obstetric  Diagnosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treatment.     By 

Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Seeond  Revised  German 
Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School, 
N.  Y.  With  122  colored  figures  on  56  plates,  38  text-cuts,  and  315 
pages  of  text.     Cloth,  $3.00  net.     In  Saunders'  Hand-Atlas  Series, 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the  wealth 
of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of  great  value. 
This  text  deals  with  the  practical,  cUnical  side  of  the  subject.  The  symptoma- 
tology and  diagnosis  are  discussed  with  all  necessary  fullness,  and  the  indications 
for  treatment  are  definite  and  complete. 

New  York  Medical  Journal 

•■  The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the  scien- 
tific midwifery  of  to-day." 


SAUNDERS'  BOOKS   ON 


Schaffer  and  Norris* 
Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of 
Heidelberg.  From  the  Second  Revised  and  Enlarged  German  Edition. 
Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gynecolo- 
gist to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text. 
Cloth,  ;^3.50  net.     In  Saunders'  Hajid- Atlas  Scries. 

The  value  of  this  atlas  to  the  medical  student  and  to  the  general  practitioner 
will  be  found  not  only  in  the  concise  explanatory  text,  but  especially  in  the  illus- 
trations. The  large  number  of  colored  plates,  reproducing  the  appearance  of 
fresh  specimens,  give  an  accurate  mental  picture  and  a  knowledge  of  the  changes 
induced  by  disease  of  the  pelvic  organs  that  cannot  be  obtained  from  mere 
description. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous.  We 
commend  it  most  earnestly." 

Galbraith*s 
Four  Epochs  of  Woman's  Life 

Second  Revised  Edition — Recently  Issued 


The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By 
Anna  M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of 
Medicine,  etc.  With  an  Introductory  Note  by  John  H.  Musser, 
M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
i2mo  of  247  pages.     Cloth,  ;^i.50  net. 

MAIDENHOOD,    MARRIAGE,    MATERNITY,    MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive  manner, 
those  truths  of  which  every  woman  should  have  a  thorough  knowledge.  Written, 
as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped  even  by 
those  most  unfamiliar  with  medical  subjects. 

Birmingham  Medical  Review,  England 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public.  But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  mam  wise  and  wholesome." 


GYNECOLOGY  AND    OBSTETRICS. 


Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaf- 
fer, of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     In  Smdidcrs'  Hand-Atlas  Scries.     Cloth,  $3.00  net. 

RECENTLY  ISSUED 

Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee's 
Obstetrics  for  Nurses 


Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals,     i  2mo  \olume  of  460  pages, 

fully  illustrated.  Cloth,  $2.50  net. 

JUST  ISSUED-riEW  f2nd)  EDITION 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  eight  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Edgar.  M.  D., 

Pra/essor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University .  A-ew  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  mv  nurses,  and  students  as  well," 


i6      SAUNDERS'   BOOKS  ON  GYNECOLOGY  AND   OBSTETRICS. 

American  Pocket  Dictionary  ^''*'^  ""'^'TusuS 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American 
Academy  of  Medicine.  Over  550  pages.  Full  leather,  limp,  with 
gold  edges,     ^i.oo  net ;  with  patent  thumb  index,  $1.2^  net. 

James  W.  Holland.  M.  D., 

Professor   of  Medical    Chemistry    and    Toxicology    at  the  Jefferson    Medical    College, 

Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the   compact  size  and  attractive   exterior.     I 
can  recommend  it  to  our  students  without  reserve." 

Recently  Issued 

Cra£(in*s  Gynecology.  New  i6th)  Edition 

PLssentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  215  pages,  62  illustrations.  Cloth,  $1.00 
net.     ///   Saunders'   Question- Compend  Series. 

The  Medical  Record,  New  York 

"  A  handy  volume  and  a  distinct  improvement  of  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Boisliniere*s   Obstetric   Accidents,   Emer|»encies,   and 
Operations 

Obstetric  Accidents,  Emergencies,  and  Operations.  By 
the  late  L.  Ch.  Boisliniere,  M.  D.,  Emeritus  Professor  of  Ob- 
stetrics, St.  Louis  Medical  College  ;  Consulting  Physician,  St.  Louis 
Female  Hospital.     381  pages,  illustrated.     Cloth,  ^2.00  net. 

British  Medical  Journal 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience,    its  merit  lies  in  the  judgment  which  comes  from  experience." 

AshtOn*S    Obstetrics.  Recently  Issued— New  (6th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  256  pages,  75  illustrations.  Cloth,  ;$i.oo 
net.     In  Saunders'  Question- Compend  Series. 

Southern  Practitioner 

"  An  excellent  little  volume  ccataining  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 

Barton  and  Wells'  Medical  Thesaurus  Recently  issued 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred 
M.  Barton,  M.  D.,  As.sistant  to  Professor  of  Materia  Medica  and 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  and 
Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryngology,  George- 
town University,  Washington,  D.  C.  l2mo  of  534  pages.  Flex- 
ible leather,  1^2.50  net ;  with  thumb  index,  ^3.00  net. 


